Enhancing equitable access to virtual care in Canada: Principle-based recommendations for equity

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Organization: Public Health Agency of Canada

Published: 2022

Report of the Task Team on Equitable Access to Virtual Care

June 29, 2021

Health Canada is the federal department responsible for helping the people of Canada maintain and improve their health. Health Canada is committed to improving the lives of all of Canada's people and to making this country's population among the healthiest in the world as measured by longevity, lifestyle and effective use of the public health care system.

Table of contents

Foreword

The COVID-19 pandemic has forced us to innovate quickly and change how we work to adapt to new realities. It caused significant disruption to the delivery of in-person health services, and forced us to re-think the way we deliver care. The pandemic has served as a catalyst to accelerate the rapid deployment of virtual services so Canadians can safely access the care they need.

As co-Chairs of the Federal, Provincial and Territorial Virtual Care/Digital Table, we have had the opportunity to provide guidance and direction to the collaborative federal, provincial and territorial effort to adopt quality virtual care in Canada. We have learned that while virtual care holds the promise of more accessible, integrated, and convenient patient care, to do so it must be intentionally designed to enhance equity and ensure that all Canadians can benefit from this modality of care. The Equity Task Team was created to apply an equity lens to the design and implementation of virtual care and develop principle-based recommendations for a collaborative approach to equitable virtual care across stakeholders and jurisdictions.

As we look beyond the pandemic and reimagine health service with integrated virtual care the work of the Equity Task Team can serve as a guide to co-design and deploy deliberate, principle-based virtual care that enhances equity in health care.

As co-Chairs of the FPT Virtual Care and Digital Health Table, we would like to commend Dr. Affleck and the Equity Task Team for the clear and robust quality of this report.

Jo Voisin
Associate Assistant Deputy Minister, Strategic Policy Branch, Health Canada
Co-Chair FPT Virtual Care/Digital Table

Sandra Cascadden
Associate Deputy Minister, Health and Wellness, Nova Scotia
Co-Chair FPT Virtual Care/Digital Table

Message from the Chair

As Chair of the Task Team on Equitable Access to Virtual Care, I would like to express my gratitude to the members of the team for their invaluable contribution to this report. Their collective expertise and wisdom have contributed immeasurably to the development of principle-based recommendations that if pursued will promote digital health equity in the publicly funded Canadian health service.

Listed below are the names of Equity Task Team members.

Name Position
Dr. Ewan Affleck, Chair Senior Medical Advisor - Health Informatics - College of Physicians & Surgeons of Alberta, Yellowknife Northwest Territories
Shirley Bourdouleix Nurse Consultant, Indigenous Services Canada, Ottawa
Guy MacLaren Manager, Program Delivery for Indigenous Services Canada, Ottawa
Owen Adams Senior Advisor to the CEO - Canadian Medical Association, Ottawa
Christine Meyer Provincial Director, Equitable Access Development, Population Health and Value-Based Health Systems, Ontario Health, Toronto
Dr. Darren Larsen Chief Medical Information Officer, OntarioMD, Toronto
Jean Harvey Director of the Canadian Population Health Initiative, CIHI, Ottawa
Liris Smith Director of Care and Community, Yukon
Dr. Genevieve Moineau President and CEO, Association of Faculties of Medicine of Canada, Ottawa
Yasir Khalid Patient representative
Marci Gillespie Assistant Director, Canada Health Act Division, Health Canada, Ottawa
Matthew Howland Senior Policy Analyst, Canada Health Act Division, Health Canada, Ottawa
Laura Etherden Senior Policy Advisor, National Initiatives Unit, Health Canada, Ottawa
Michael Church Carson Policy Analyst, National Initiatives Unit, Health Canada, Ottawa
Bennett Jovaisas Policy Analyst, Mental Health Unit, Health Canada, OttawaM
Patricia Debergue Section Head, Medical Devices Research Centre, National Research Council, Montreal
Denis Laroche Team Lead, Medical Devices Research Centre, National Research Council, Montreal
Kajan Ratneswaran Health Canada Secretariat, Senior Policy Analyst, Health Care Innovation Secretariat, Health Canada, Ottawa
Jennifer Bunning Policy Analyst, Health Care Innovation Secretariat, Health Canada, Ottawa
Erica Chen Policy Analyst, Health Care Innovation Secretariat, Health Canada, Ottawa

Executive summary

Virtual Care in Canada: The current context

The COVID-19 pandemic resulted in provincial and territorial governments rapidly accelerating the deployment of virtual care across Canada so that Canadians were able to effectively access publicly-funded health care services in a safe, physically distanced manner. However, the rapid deployment of virtual care impaired the capacity to constructively apply the appropriate design features required to promote quality of care, and specifically equitable health services. It is recognized that virtual care, if not designed thoughtfully, has the potential to exacerbate the digital divide, and compromise health equity.

To promote collaboration, the Federal, Provincial, Territorial (FPT) Virtual Care/Digital Table was struck in March 2020 with a mandate to consider and develop a proposed plan for accelerating the deployment of virtual care in Canada both during COVID and for the longer-term. In addition, the Virtual Care Expert Working Group ("Expert Working Group") was struck to provide advice and guidance on FPT work on virtual care. As part of this work, equity emerged as a critical issue, and there was interest from FPT governments to examine how best to ensure equitable access to virtual care within the publicly-funded health care system.

Equity in virtual care, a subset of digital health equity, is defined by the Equity Task Team as:

"The provision of remote health services using any form of communication or information technology to facilitate or maximize the quality of patient care by joining patients and/or members of their circle of care in a manner that ensures an absence of avoidable or remediable differences among groups of people based on digital or social determinants of health."

Our mandate

The Task Team on Equitable Access to Virtual Care (Equity Task Team) was created under the Virtual Care Expert Working Group with a mandate to develop a principle-based framework for equitable access to virtual care and provide guidance and recommendations on the concrete actions that FPT governments can take to ensure that virtual care promotes equity as a critical dimension of quality care. The Equity Task Team took a pan-Canadian approach to examining equity in virtual care, with work focused on four stepwise thematic exercises, including: defining equity in virtual care and identifying barriers to equitable access; identifying domestic and international best practices aimed at enhancing equitable access to virtual care; developing high-level principles for the design of virtual care; and, developing recommendations based on the established design principles.

What we found

Among the key findings was that Canada lacks a defined pan-Canadian approach to, or vision for, equity in virtual care services, in the same way that it lacks a pan-Canadian approach to health equity in care delivery. This absence of vision and design principles to guide the equitable deployment of virtual care contributes to and potentially exacerbates underlying inequities in the provision of high-quality digital care.

A lack of health data related to equity makes it difficult to understand the scope of the problem in Canada, as well as to determine the differential impact for underserved populations. In particular, a dearth of disaggregated data is of significant concern in designing virtual care services in an equitable manner.

The Equity Task Team suggests that it is critical to examine both social and digital determinants of health in examining barriers to equity in access to virtual care. In the literature, there is a general tendency to focus on the social determinants in studying inequity in health, which in the context of digital health leads to the exclusion of important, uniquely digital factors that can promote inequity in virtual care.

In addition, we recognize that the widespread deployment of virtual care should not exacerbate pre-existing inequities in the broader health system. In particular, there is a need to ensure that virtual care is embedded in health care systems in such a way that is integrated and supports publicly-funded health care.

In exploring domestic and international best practices, we found that the development of an overarching vision and governance for virtual care, and shifting to patient- and caregiver-centred design of care to be critical enablers of equity. Other critical enablers include having access to high-quality data and evidence to support equitable design of virtual care, interoperability and a commitment to the promotion of continuity of care.

Moving forward: Our recommendations for a principle-based framework

Based on the examination of barriers to equitable virtual care access and best practices, the Equity Task Team suggests that equity should be a critical foundational element for the design of virtual care. To this end, a Principle-based vision for equitable virtual care is proposed that can serve as a unifying framework for system design. The vision is arranged in five core domains:

  1. There is a shared and agreed upon pan-Canadian vision for digital health equity.
  2. All residents of Canada, irrespective of age, race, ethnicity, gender, sexual orientation, location, income, housing, education, disability, faith, health status, citizenship, culture, stigmatizing conditions, and other socio-demographic characteristics will benefit from patient- and caregiver-centered virtual care design.
  3. Health care providers will be competent to deliver equitable virtual care.
  4. Supporting infrastructure and virtual care technology will foster digital health equity.
  5. The collection and sharing of data to monitor and evaluate virtual care for indices of digital health equity will support transparency, accountability and continuous quality improvement.

Based on the proposed Design Principles, the Equity Task Team recommends that FPT governments in collaboration with a broad range of stakeholders, including patients, providers, and Indigenous groups establish a pan-Canadian Digital Health Equity Working Group, with a mandate to align jurisdictions around a common effort to drive progress on enhancing equitable access to virtual care. This Working Group will be tasked with coordinating efforts and working with relevant partners at a pan-Canadian level to implement the specific recommendations under each of the five Design Principles. The pan-Canadian Digital Health Equity Working Group would report to the FPT Virtual Care/Digital Table to ensure alignment with the broader virtual care agenda.

The COVID-19 pandemic has created a policy window for accelerating health care reform. As governments look to embed virtual care as a permanent feature of publicly funded health systems, the Equity Task Team urges jurisdictions to deliberately design and implement virtual care in a way that enhances equity and more broadly supports a more equitable, publicly funded health care system. A central feature of this approach is policy alignment across jurisdictions around an evidenced-based vision, which will promote regional consistency of service, economies of scale and support patient-centric quality care.

Figure 1: Recommendations for a principle-based framework
Figure #. Text version below.
Figure 1 - Text description

Recommendations include:
A shared upon pan-Canadian vision for digital health equity.

  • Establish a model for oversight and accountability.
  • Establish a national Digital Health Equity Accord.
  • Set a common and agreed-upon pan-Canadian definition of digital health equity.
  • Establish a pragmatic framework for the pan-Canadian alignment of health care legislation, regulations, standards, and policy to support vision for Canadian digital health equity.
  • Build a business case for a fully equitable virtual care system in Canada.
  • Reports to the Federal, Provincial and Territorial Virtual Care/Digital Table.

All residents of Canada will benefit from patient and caregiver-centered virtual care design.

  • Include meaningful representation from individuals from traditionally underserved groups.
  • Design virtual care to benefit all residents of Canada including those traditionally underserved.
  • Work with provincial and territorial governments, industry partners, patients, providers, and other stakeholders to:
    • Promote patient virtual care literacy through the creation of training and knowledge resources.
    • Promote standards of virtual care design that enshrine patient ownership and timely access to their health information, patient-centric health information integration, team-based virtual care.

Health care providers will be competent to deliver equitable virtual care.

  • Develop model core competencies for equitable virtual care to be promoted to all health professional educational faculties and certifying bodies, and a resource guide that can inform curriculum development for undergraduate, postgraduate and continuing professional development.
  • Leverage best practices in digital age education from other countries.
  • Partner with professional colleges and education groups to promote virtual care literacy curricula and programing for providers.
  • Develop a framework for inter-professional teamwork to support equitable pan-Canadian virtual care.
  • Work with accreditation bodies, sector specific associations and organizations to promote staff competency in virtual care equity.

Supporting infrastructure and virtual care technology that fosters digital health equity.

  • Leverage and work with Innovation, Science and Economic Development Canada to ensure that Canadians, including those that live in rural and remote populations, will have access to reliable high-speed internet by 2030.
  • Conduct a review and set recommendations for equitable and affordable access to high-speed internet for all people living in Canada.
  • Foster technology interfaces that promote accessible design for those with unique needs (including but not limited to language barriers, and disabilities).
  • Establish a plan to promote universal access to virtual care for those with insufficient access to the technology, broadband, digital literacy skills, or other factors, including but not limited to the potential use of public-facing virtual care kiosks.
  • Identify and promote procurement standards that support equity in virtual care service.
  • Promote the pan-Canadian integration of technology to support equitable care.

The collection and sharing of data to monitor and evaluate virtual care for indices of digital health equity.

  • Collaborate with pan-Canadian health organizations and other organizations such as the Centre for Digital Health Evaluation to collect comparable data to measure and evaluate the equity of virtual care using core indicators according to set principles of patient and community control, including Indigenous data governance principles (ownership, control, access, and possession).
  • Partner with the Canadian Institute for Health Information (CIHI) in collaboration with the provinces and territories to report regularly on equity in virtual care.
  • Partner with Statistics Canada to collect statistics on digital health equity and virtual care, through its Canadian Community Health Survey.
  • Identify and seek to address data gaps in virtual care equity for certain populations including but not limited to Indigenous people.
  • Seek to identify legislative and policy barriers that impair the sharing of data around virtual care equity.
  • Promote the use of standardized metrics and benchmarks for collecting equity based virtual care stratifiers across Canada.

Definitions and taxonomy

In Canada, a lack of definitional rigour and consensus on the meaning of terms used in digital health may have implications for how programs and policy are developed, measured, and evaluated. As such, the Equity Task Team set out to clearly define both the terms used in this report, as well as the inter-relationship of the domains discussed. It is hoped that the definitions and relationships help move the Canadian digital health industry toward a standardized and uniform lexicon and taxonomy.

The Equity Task Team worked collaboratively with the Alberta Virtual Care Working Group to establish the definitions and taxonomy used in this report.

The Equity Task Team adopted Canada Health Infoway's definition of digital healthFootnote 1, which is defined as:

"The use of information technology/electronic communication tools, services and processes to deliver health care services or to facilitate better health."

For the purpose of this report, equityFootnote 2 is defined as:

"The notion of being fair and impartial as an individual engages with an organization or system."

The Equity Task Team broadly defines digital health equity as:

"The provision of equitable health service using digital communication or information tools for the collection, exchange and use of health-related information for purposes of promoting quality care."

Equity in virtual care, a subset of digital health equity, is defined by the Equity Task Team as:

"The provision of remote health services using any form of communication or information technology to facilitate or maximize the quality of patient care by joining patients and/or members of their circle of care in a manner that ensures an absence of avoidable or remediable differences among groups of people based on digital or social determinants of health."

The definition of virtual careFootnote 3, derived from The Women's College Hospital Institute for Health System Solutions, is:

"Any interaction between patients and/or members of their circle of care occurring remotely, using any forms of communication or information technology with the aim of facilitating or maximizing the quality of patient care."

The Equity Task Team defines circle of care as:

"The group of healthcare providers and caregivers who have consent to access a patient's health information to benefit the patient's health and wellness."

Secure messaging is defined by the Equity Task Team as:

"The asynchronous exchange of information between providers and patients, or between providers, through electronic platforms (e.g. texting, e-mail) that adhere to the standards of safety and privacy."

The Equity Task Team adopted Organisation for Economic Co-operation and Development's (OECD) definition of digital divideFootnote 4, which refers to:

"The gap between individuals, households, businesses and geographic areas at different socio-economic levels with regard to both their opportunities to access information and communication technologies and to their use of the Internet for a wide variety of activities."

The extent to which one is impacted by the digital divide is often determined by both social determinantsFootnote 5 and digital determinants of health. Social determinants of health, as defined by World Health Organization, are:

"Non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems."

Although digital determinants of health are a subset of social determinants, for the purposes of this report we have chosen to focus upon them as a unique set of factors that have an explicit and discrete impact on digital health equity. Canada Health Infoway defines digital determinants of healthFootnote 6 as:

"Critical aspects of social determinants of health that may be amplified in a digital context."

The Equity Task Team uses "underserved populations" as an umbrella term to reference the idea of:

"communities that are not well served by the health systemFootnote 7."

The term "underserved" emphasizes that systems are not designed to reflect the needs of certain populations, rather than placing the focus on the social identities of these groupsFootnote 8. Other terms that have been used to describe the same issue include marginalized populations and vulnerable populations. Marginalized populations are defined as:

"groups and communities that experience discrimination and exclusion (social, political and economic) because of unequal power relationships across economic, political, social and cultural dimensionFootnote 8."

Similarly, vulnerable populations are defined as

"groups and communities at a higher risk for poor health as a result of the barriers they experience to social, economic, political and environmental resources, as well as limitations due to illness or disabilityFootnote 9".

Introduction

Virtual care is defined as "any interaction between patients and/or members of their circle of care occurring remotely, using any forms of communication or information technology with the aim of facilitating or maximizing the quality of patient careFootnote 3". Virtual care may be provided either synchronously or asynchronously through modalities such as, but not limited to, telephone, video, secure messaging, and remote monitoring. In this context, virtual care is envisioned as another modality of care within the publicly-funded health care system that complements in-person care and is used at the clinical discretion of the patient-provider dyad with the ultimate aim of providing high-quality care.

"Virtual care should become a central pillar of a new health delivery system that ensures all Canadians get the right care at the right time."

–Dr. Sacha Bhatia (Population Health and Value Based Care Executive, Ontario Health) and William Falk (Adjunct Professor, University of Toronto; Innovation Fellow, Women’s College Hospital)

Virtual care offers a myriad of potential benefits relating to reduced wait times, improved clinical outcomes, cost and efficiency, and the ability to expand access to services (e.g., enhance access to primary and specialist services in rural and remote regions, timely care)Footnote 10. Over the years, virtual care has been recognized as a key feature of high-performing health systems (e.g., Kaiser Permanente), and is seen as a critical tool to enhance access to comprehensive, patient-centered integrated care and improve health outcomes. Prior to the COVID-19 pandemic, Canadian health systems were slow to shift towards virtual services, despite evidence of the value of virtual care both to providers and patients. Uptake was relatively slow due to range of governance, policy and technical barriers, including a lack of physician remuneration codes for virtual care. Despite these barriers, in 2018, 63% of Canadians wanted to receive care services virtuallyFootnote 10.

The COVID-19 pandemic has been a catalyst for the adoption of virtual care, with provinces and territories moving quickly to enable access, including:

A national poll by CMA-Abacus found that approximately half of Canadians (47%) have used virtual care since the COVID-19 pandemic was declared - 91% of which were satisfied with their experienceFootnote 11. In contrast, according to a survey commissioned by Canada Health Infoway, only 10-20% of Canadians reported using virtual care in 2019Footnote 12. While there is variation in modality by geographic region, age, and sex, communication with care providers was most likely to occur over telephone, followed by video, then secure messagingFootnote 13. Provincial and territorial efforts to increase access to virtual care in response to the pandemic has resulted in significant increase in virtual visits, with about 60% of visits being virtual (telephone, videoconferencing, texting/email) in April 2020 (compared to 10-20% in 2019). While this figure has fallen to 36% in April 2021Footnote 14, it continues to be an important modality of care. Meanwhile, in-person visits for non-COVID related issues decreased from 68% in August 2020 to 61% in April 2021Footnote 14.

Figure 2: Modality of most recent non-Covid-19 related visit
Figure 2. Text version below.
Figure 2 - Text description
Modality April
2019
April
2020
May
2020
June
2020
July
2020
Aug
2020
Jan
2021
Feb
2021
Mar
2021
April
2021
In-person 85% 39% 45% 51% 67% 68% 55% 58% 59% 61%
Video 3% 12% 9% 9% 8% 7% 6% 9% 6% 6%
Telephone 10% 41% 35% 30% 22% 21% 31% 32% 31% 31%
Messaging/ Email 1% 4% 2% 3% 1% 4% 2% 1% 2% 0%
All virtual (phone, video, messaging) 14% 57% 49% 41% 30% 28% 40% 41% 38% 36%

Source: Canada Health Infoway, 2021

While provinces and territories significantly enhanced virtual services within the publicly funded health care system during the pandemic, virtual care has largely been implemented as a stop-gap/temporary measure without significant consideration given to how it can be seamlessly integrated into service workflows and existing technology, or designed with patient or provider experience in mind. In response, federal, provincial and territorial governments are working together to build on progress to date, with the recognition that virtual care needs to become a permanent and integrated facet of publicly-funded health service in Canada.

In this context, there was interest among FPT governments to explore the issue of equity in access to virtual care. Concern has been expressed that the rapid adoption of virtual care during the COVID-19 pandemic could potentially amplify existing health care inequities by exacerbating pre-existing gaps in digital literacy, access to broadband, and by compromising continuity of care. The capacity of social determinants of health (e.g., gender, income, ethnicity) and digital determinants of health (i.e., policy alignment, access to broadband and virtual care technology) to hinder access to care for underserved populations is well recognized.

Further, private health care vendors have been able to capitalize on the recent growth in virtual care in Canada to deliver service that is frequently episodic in nature, often not linked to in-person health services, and subjects patients to a fee for access to private virtual care platforms that provide services that are now insured by provincial and territorial health care insurance plans. These private virtual care platforms often target the needs of unattached patients and those patients who have difficulty accessing timely care. Given the significant and increasing number of private vendors of virtual care services, there is concern that out-of-pocket charges for health care services is further exacerbating the aforementioned inequities. In addition, it is suggested that some health providers providing care through private virtual care platforms may not have adequate knowledge of community-based health care services and resources, and as a consequence the interaction with the patient is not connected with the broader patient record or shared with the patient's regular health provider (e.g., family physician or specialist). Taken together, there is an urgent need to address issues relating to equitable access to virtual care to prevent further fragmentation of care.

The demand for virtual care services remains very high; 92% of Canadians want technology that makes health care more convenient and 86% of Canadians believe that technology can help solve issues within our health care systemsFootnote 12. Yet, there are glaring gaps that need to be addressed in order for digital health equity to be achieved. For instance, 60% of surveyed Canadians feel that they do not have adequate knowledge of digital health applications and services, and over a quarter of Canadians do not have reliable access to internet serviceFootnote 12. As a result, there is a pressing need to promote a rational digital health architecture that mitigates health service inequities to ensure that all residents of Canada are able to reap the benefits of virtual care.

Task Team on Equitable Access to Virtual Care - Current pan-Canadian context

Since March 2020, FPT governments have been working cooperatively to align and accelerate efforts on virtual care. To support pan-Canadian collaboration, the FPT Virtual Care/Digital Table was struck to discuss digital health and virtual care in response to the COVID-19 pandemic, including areas where efforts at a federal or national level could support rapid deployment of regional virtual care services. In addition, to better inform the work of the FPT Virtual Care/ Digital Table, the Virtual Care Expert Working Group ("Expert Working Group") was created to provide advice and guidance on FPT work to rapidly deploy virtual care in Canadian health systems.

In May 2020, the Government of Canada announced an investment of $240.5M, of which $200M is helping provinces and territories accelerate their efforts to meet health care needs through virtual tools and approaches. The same month, FPT Deputy Ministers of Health agreed to a shared agenda for the work focused on three streams:

Equity in access to virtual care became a major theme in discussions at both the FPT Virtual Care/Digital Table and Expert Working Group. The Table members expressed strong interest to ensure that governments are well-positioned to address/avoid unintended consequences related to equity arising from the widespread uptake and use of virtual care.

As part of the FPT work, governments are working collaboratively to develop a shared policy framework, which identifies barriers and opportunities for the long-term adoption of virtual services as a mode of health care delivery and a critical aspect of publicly funded health care. Equity is identified as one of the key policy enablers for the effective long-term adoption of publicly insured, universal, and integrated quality virtual care.

Given the significance of equity and the need to do targeted work, the FPT Virtual Care/Digital Table created the Equity Task Team under the Expert Working Group to do focused work on equity, with a mandate to provide:

Overview of Equity Task Team

The mandate of the Task Team on Equity is to develop a principle-based framework for equitable access to virtual care and provide guidance and recommendations on the concrete actions that FPT governments could take to ensure that virtual care is equitable, as a critical dimension of quality.

The efforts of the Task Team were divided into four key thematic areas:

  1. Problem definition:

Identify and define barriers and obstacles to equitable access to virtual care health services, particularly for rural and remote populations, Indigenous peoples, disabled, as well as for other underserved populations.

  1. Best practices:

Identifying best practices and standards of excellence within Canada and internationally that support the equitable delivery of virtual health care.

  1. Define principles:

Considering steps 1 and 2, develop a principle-based vision for virtual care equity in Canada.

  1. Recommended actions:

Propose recommendations and pragmatic actions that will promote the realization of the vision for equitable virtual care in Canada.

Approach

Several approaches were used to advance the work of the Task Team:

Deliverable
A final report with concrete recommendations on actions that governments and others can take to enhance equity in virtual care will be delivered to the FPT Virtual Care/ Digital Table for consideration.

Section 1: Barriers to equitable access to virtual health care services

Virtual care offers significant potential to address both the short-term needs related to COVID-19, as well as increasing access to high-quality health services over the longer-term. Despite the potential of virtual care, patients that most stand to benefit are also often those least able to access and take advantage of care delivered virtually. There is consensus that certain populations have inequitable access to virtual care due to a diverse range of characteristics (e.g., based on age, geography, language, income and education, gender). Evidence suggests that this divide reflects barriers to accessing care delivered virtually, rather than preferences regarding the use of virtual care among different groupsFootnote 15.

"Out of necessity, virtual care was adopted to preserve some form of access to care. Going forward, we need to make sure that virtual care is effectively integrated and delivered equitably. Our pivot to virtual care was swift and at times reliant on temporary measures that must now

– Dr. Ann Collins (CMA President, 2020-2021)

Based on internal survey results and a literature review, there are three broad and interconnected categories of factors that impact the equitable access to virtual care. These factors all fall under the rubric of social determinants of health. The World Health Organization defines social determinants of health as "the conditions in which people are born, grow, live, work and ageFootnote 16." The three factors are:

To achieve equity of access and quality care, integrating virtual care into public health systems will require careful consideration of the variability in available resources and infrastructure in different communities and contexts. An intersectional perspective, which involves examining these factors in relation to other social stratifiers, such as class, race, ethnicity, and sexual orientation, is essential to understand how these social categories interact to create specific experiences of inequity in accessing and using virtual care services. In addition, digital/systemic issues need to be added to the matrix in order to achieve a just appraisal of the complex dynamic equity ecosystem, and identify mitigating strategies for the just deployment of equitable virtual care. The Task Team identified the following principle factors for consideration.

Individual determinants of digital health:

Structural and systemic determinants of digital health:

While the vitual walk-in clinic model fills a need for Canadians who lack access to services - particularly where they do not have a primary care physician - the care is usually siloed, episodic and disconnected from primary care. Taken together, this policy disorder can promote inequities in virtual care service.

Figure 3: Digital determinants of health equity
Figure 3. Text version below.
Figure 3 - Text description

Graphic: A cartoon physician standing next to a bubble chart that organize digital determinants of health equity based on individual characteristics, digital and systemic factors, and pre-existing inequities.

Individual characteristics: income and education; geography; pre-existing health conditions and disabilities; age, race, ethnicity, gender, culture.

Digital & Systemic Factors: provider literacy; interoperability; virtual care technology

Pre-existing inequities: legislation, policy, and regulation

Data and evidence on inequities in access to virtual care in Canada

With specific regard to virtual care, disaggregated data on use by various social groups (i.e., age, gender, income, geographic region) and the extent to which these groups face access barriers are extremely limited. However, some emerging data from the Centre for Digital Health Evaluation suggests that all groups in Ontario (regardless of age and income) have been just as likely to use virtual care throughout the COVID-19 pandemicFootnote 29. This is likely linked to the fact that the vast majority of virtual care was delivered through a modality of communication that is almost universally accessible, the telephone, as opposed to other modalities such as video conferencing or secure messagingFootnote 30. This was reflected in a recent finding from Infoway, which suggested that older adults were more likely to use telephone to seek virtual care compared to younger adults across Canada. Expectedly, it also found that younger adults were more likely to use secure messaging and video-conferencing compared to older adultsFootnote 20.

The lack of comprehensive disaggregated data by specific demographic, province and territory poses challenges to assessing the extent to which certain groups face difficulties in accessing virtual care services. This is compounded by the fact that limited research exists to provide a comprehensive understanding of the difficulties that specific social groups encounter in accessing virtual care, including the diverse needs within social groups. While it is widely accepted that a broad range of social and structural barriers (e.g., lack of digital literacy, access to broadband and technology, limited culturally appropriate services) impacts equitable access to virtual care for underserved populations, the deficiency in the availability of data and research makes it difficult to effectively characterize the problem. This work is especially important given evidence that the needs of underserved populations are often neglected not only in virtual care, but in the health care system as a whole.

"The pandemic has exacerbated existing disparities related to the social determinants of health. Where we live, how we earn a living, our educational opportunities, financial circumstances affect our health outcomes in dramatic ways. We need to make certain that digital

- Ann Heesters, Ph.D. (Professor, Dalla Lana School of Public Health, University of Toronto)

As one example, the paucity of data on digital health literacy amongst the population has been a longstanding issue, with the lack of data being of particular concern now that virtual care has been widely deployed in response to COVID-19 in Canada. For instance, while the OECD found that between 36%-60% of Canadian adults had low health literacy levels in 2018Footnote 30, this paper did not include information specifically relating to digital health literacy. Moreover, efforts made in 2012 to collect data on digital literacy skills of Canadian adults (e.g. problem solving with technology, overall levels of reading), such as the Programme for the International Assessment of Adult Competencies, have not specifically measured digital health literacyFootnote 31. Since virtual care will continue to remain a core modality of care post-pandemic, there is a strong need to collect data relating to digital health literacy to facilitate digital health equity amongst all groups.

Although there is clear documentation of certain digital/systemic determinants of virtual care accessibility such as high speed internet capacity and cost, many digital/systemic determinants of digital health remain unstudied. A means of evaluating the index of integration or interoperability of a digital health ecosystem and relating that to indices of quality of care, including health equity, would be a very valuable exercise. Similarly, a study of the impact of provider digital literacy on quality of care, or an evaluation on the extent and impact of policy variations on the integrity of virtual care capacity and accessibility would help inform curricular and policy development and alignment.

Section 2: Best practices for equitable access to virtual care

The purpose of this section is to provide a high-level overview of domestic and international best practices in equitable virtual care, with a view to exploring approaches that could inform the development of principles and solutions to the barriers identified in the previous section. These best practices were identified through an internal survey, as well as a high-level literature review.

A majority of pragmatic approaches to optimizing equitable virtual care found in this section involve modification of the digital /systemic determinants of virtual care equity. Individual determinants of health inequity - which for the most part transcend virtual care and impact all health service - are by their very nature more complex and challenging issues to address.

Examples of potential large-scale changes, which are especially relevant in the Canadian context, include the development of a pan-Canadian vision for equitable virtual care, and shifting from a provider-centered to patient and caregiver-centered health information approachFootnote 32. Other key areas of relevance to enhancing equity in access to virtual care include data and evidenced based policy development/design, interoperability, and the need to promote continuity of care.

Overarching vision for digital health equity:

Governance and Strategy for Implementation

There are various requirements needed to deploy and manage an equitable pan-Canadian digital health network. These include a national framework, clear oversight, and a strategy for implementing digital health care in an equitable manner. Governance, in particular, is central to reforming this modality of care. According to the WHO, "governance in the health sector refers to a wide range of steering and rule-making related functions carried out by governments/decisions makers as they seek to achieve national health policy objectives that are conducive to universal health coverageFootnote 33. In the Canadian context, this involves working across jurisdictions and with the private sector to ensure transparency and accountability within the health care sector.

“Beyond the design of research and clinical services, it is important to have ongoing quality improvement processes that ensure rapid identification and iterative improvement of equity and safety within virtual care.”

– Dr. Allison Crawford (Associate Chief, Virtual Mental Health and Outreach, The Centre for Addiction and Mental Health; Professor, Dalla Lana School of Public Health, University of Toronto)

Data and evidence-based policy for equity

The virtualization of care is rapidly generating a significant volume of data, which can provide valuable insight on patient and provider experiences, health outcomes, and other indicators of system performance. Collecting this health data, particularly for underserved populations, can help identify specific health care needs. Likewise, understanding the population health needs of underserved groups can help identify barriers to implementing health equity initiatives. By using an interdisciplinary approach consisting of health, social care, behavioural, and socioeconomic data, the needs of underserved groups can be better understood. In turn, this facilitates effective, efficient, and equitable care within the health care system.

Patient and caregiver-centered approaches to equitable virtual care:

Inclusive design of virtual care and needed supports for patients and providers to fully take advantage of virtual care

Inclusive design of health technology, which focuses on user-friendly platforms, cultural/faith-based diversity, and accessibility, is central to ensuring patient- and caregiver-centred virtual care. There are domestic and international examples of jurisdictions building virtual care platforms that are targeted to address the needs of specific underserved populations, and develop patient-centric digital systems that are aimed at enhancing coordinated, longitudinal patient care. Patients and providers will also need targeted supports to ensure that they are able to effectively leverage the virtual care to improve care, with a particular focus on digital literacy.

As the COVID-19 pandemic continues, digital health literacy has become increasingly relevant to support virtual care. For instance, there has been a growing need to ensure that both patients and providers can access, understand, and use appropriate devices and applications for health-related purposes (i.e. virtual appointments)Footnote 39 to engage in quality care in a physically distanced manner. Higher levels of digital health literacy for patients are associated with increased levels of engagement, which helps to ensure that patients are able to take greater advantage of the various benefits of virtual careFootnote 40. As digital health literacy remains a barrier to accessing virtual care, especially for underserved populations, there is a need for structural measures that promote digital health literacy.

Infrastructure, interoperability and technology

A review of international and domestic policies showcases the need to ensure that the right infrastructure is in place along with interoperable systems and appropriate technology to enable the effective adoption and use of virtual care. Interoperability is defined as "the ability of two or more systems or components to exchange information and to use information that has been exchangedFootnote 5". Inclusive and nimble data interoperability that enables enterprise health information exchange, is an essential feature of comprehensive patient-centric virtual care. Further, interoperability within and across health care systems, promotes the capacity to collect large datasets, which support clinical decision support, analytics, machine learning, and artificial intelligenceFootnote 4.

"Virtual care focuses on the use of technology to support patients in the community and to deliver care directly to them. Used well, it improves access to care and can greatly enhance the patient experience."

-- Dr. Edward Brown (Founding CEO, Ontario Telemedicine Network)

Major virtual care modalities, meaning telephone, video, secure messaging and remote monitoring, coupled with high-speed internet are the core elements of a mature virtual care environment.

Connected for Success, launched by Rogers, offers high-speed, low-cost internet to subsidized tenants, and to individuals receiving income or disability support in Ontario, New Brunswick and Newfoundland. Internet for Good™ is a program launched by Telus in partnership with the governments of BC and AB, and provides affordable internet to low-income single parent households. Some provinces, such as New Brunswick, Saskatchewan, and Nova Scotia, have plans to supply devices to older adults in nursing homes for access to virtual care and to address loneliness due to physical distancing.

Section 3: High-level design principles

The development of high-level virtual care equity Design Principles was informed by the findings outlined in sections 1 and 2, an internal survey, and subsequent Task Team written input and deliberations. The Task Team recognized that a priority in the crafting of Design Principles was the need for a national vision and framework for equitable care, and the necessity to shift from a provider-centered to patient- and caregiver-centered digital health focus.

These high-level Design Principles articulate the key elements of a national vision for equitable virtual care. Virtual care equity is considered a subset of digital health equity, which we have defined as the provision of equitable health service using digital communication or information tools for the collection, exchange and use of health-related information for purposes of promoting quality care.

The Design Principles are arranged in five domains, followed by sub-principles. The five domains are:

"Virtual care has the power and ability to not only improve patient care - improve access to care - it can also make physicians' practices more efficient."

-- Dr. Gigi Osler (CMA President, 2019-2020; Professor, University of Manitoba; ENT Surgeon)

Virtual care equity design principles

  1. There is a shared and agreed upon pan-Canadian vision for digital health equity
    1. There is a common and agreed-upon pan-Canadian definition of digital health equity.
    2. Digital health equity is central to the quality of virtual care with other domains being safety, effectiveness, efficiency, timeliness and patient-centered care.
    3. Virtual care design principles should align with, and uphold, a pan-Canadian vision for digital health equity, and a commitment to equitable universal, publicly-funded health care.
    4. Health care regulations, standards, policy, and legislation will be in alignment with the vision for Canadian digital health equity.
    5. Virtual care will be integrated with and supported by publicly-funded health care.
  2. All residents of Canada, irrespective of age, race, ethnicity, gender, sexual orientation, location, income, housing, education, disability, faith, health status, citizenship, culture, stigmatizing conditions, and other socio-demographic characteristics will benefit from patient and caregiver-centered virtual care design.
    1. Patients from diverse communities will have meaningful representation at all oversight levels of virtual care design, implementation and management.
    2. Virtual care service will be inclusively designed with the active involvement of underserved groups to ensure effectiveness and relevance to their communities.
    3. All patients will have access to training and knowledge resources to enhance and strengthen their digital health literacy in a manner that accommodates their diverse needs.
    4. All Canadians will have ownership of and access to their complete, composite health and social service information.
    5. All Canadians will have their comprehensive health information follow them through their longitudinal health journey.
    6. All patients and their caregivers will have access to team-based virtual care and be recognized and treated as central members of the team.
  3. Health care providers will be competent to deliver equitable virtual care
    1. The competency of providers to deliver appropriate and equitable virtual care will be assured through education, training, licensure, and regulation;
    2. Comprehensive team-based care that supports continuity and transition of care is recognized as a core component of equitable virtual care.
    3. The competency of providers to deliver equitable virtual care will be enabled by coherently designed platforms that promote ease of use, and limit provider burnout.
  4. Supporting infrastructure and virtual care technology will foster digital health equity
    1. All Canadians, including patients and providers, will have access to a safe space, affordable high-speed internet, and virtual care technologies required to eliminate the digital divide;
    2. Virtual care technology platforms will be interoperable or functionally integrated to allow for patient information to flow effectively to all Canadians, according to set standards of patient safety, privacy and security;
    3. Virtual care technology procurement should follow set pan-Canadian standards that uphold digital health equity;
    4. Digital health equity, as a subset of digital quality of care should help drive technology requirements.
  5. The collection and sharing of data to monitor and evaluate virtual care for indices of digital health equity will support transparency, accountability and continuous quality improvement.
    1. Data collection and data sharing should be according to set principles of patient and community control, and in alignment with their diverse needs, including First Nations data governance principles of Ownership, Control, Access, and Possession (OCAP).
    2. Data collection should acknowledge and promote the importance of multi-source data, including that arising from outside the domain of traditional health care, to capture an accurate picture of the diverse Canadian health care mosaic.

Section 4: Pragmatic recommendations

The final deliverable of the Virtual Care Equity Task Team was to draft concrete recommendations to deliver upon the Principle-based vision for pan-Canadian virtual care. The recommendations were the by-products of the findings outlined in sections 1, 2 and 3 of this report, an internal survey of committee members, and a high-level literature review. Recommendations are arranged according to the five Design Principle domains.

Principle 1: There is a shared and agreed upon pan-Canadian vision for digital health equity.

Recommendation 1

Principle 2: All residents of Canada, irrespective of age, race, ethnicity, gender, sexual orientation, location, income, housing, education, disability, faith, health status, citizenship, culture, stigmatizing conditions, and other socio-demographic characteristics will benefit from patient and caregiver-centered virtual care design.

Recommendation 2

  1. The above proposed pan-Canadian Digital Health Equity Working Group will:
    1. Include meaningful representation from individuals from traditionally underserved groups.
    2. Enshrine the obligation to design virtual care to benefit all residents of Canada including those traditionally underserved.
    3. Work with provincial and territorial governments, industry partners, patients, providers, and other stakeholders to:
      1. Promote patient virtual care literacy through the creation of training and knowledge resources.
      2. Promote standards of virtual care design that enshrine:
        1. Patient ownership and timely access to their health information;
        2. Patient-centric health information integration;
        3. Team-based virtual care.

Principle 3: Health care providers will be competent to deliver equitable virtual care.

Recommendation 3

  1. The above proposed pan-Canadian Digital Health Equity Working Group will:
    1. Develop model core competencies for equitable virtual care to be promoted to all health professional educational faculties and certifying bodies, and a resource guide that can inform curriculum development for undergraduate, postgraduate and continuing professional development.
    2. Leverage best practices in digital age education from other countries.
    3. Partner with professional colleges and education groups to promote virtual care literacy curricula and programing for providers.
    4. Develop a framework for inter-professional teamwork to support equitable pan-Canadian virtual care.
    5. Work with accreditation bodies, sector specific associations and organizations to promote staff competency in virtual care equity.

Principle 4: Supporting infrastructure and virtual care technology that fosters digital health equity.

Recommendation 4

  1. The above proposed pan-Canadian Digital Health Equity Working Group will:
    1. Leverage and work with Innovation, Science and Economic Development Canada to ensure that Canadians, including those that live in rural and remote populations, will have access to reliable high-speed internet by 2030.
    2. Work with appropriate partners, to conduct a review and set recommendations for equitable and affordable access to high-speed internet for all people living in Canada.
    3. Collaborate with appropriate partners across various sectors to foster technology interfaces that promote accessible design for those with unique needs (including but not limited to language barriers, and disabilities).
    4. Collaborate with appropriate partners across various sectors to establish a plan to promote universal access to virtual care for those with insufficient access to the technology, broadband, digital literacy skills, or other factors, including but not limited to the potential use of public-facing virtual care kiosks.
    5. Identify and promote procurement standards that support equity in virtual care service.
    6. Promote the pan-Canadian integration of technology to support equitable care.

Principle 5: The collection and sharing of data to monitor and evaluate virtual care for indices of digital health equity will support transparency, accountability and continuous quality improvement

Recommendation 5

  1. The above proposed pan-Canadian Digital Health Equity Working Group will:
    1. Collaborate with pan-Canadian health organizations and other organizations such as the Centre for Digital Health Evaluation to collect comparable data to measure and evaluate the equity of virtual care using core indicators according to set principles of patient and community control, including Indigenous data governance principles (ownership, control, access, and possession).
    2. Partner with the Canadian Institute for Health Information (CIHI) in collaboration with the provinces and territories to report regularly on equity in virtual care.
    3. Partner with Statistics Canada to collect statistics on digital health equity and virtual care, through its Canadian Community Health Survey.
    4. Identify and seek to address data gaps in virtual care equity for certain populations including but not limited to Indigenous people.
    5. Seek to identify legislative and policy barriers that impair the sharing of data around virtual care equity.
    6. Promote the use of standardized metrics and benchmarks for collecting equity based virtual care stratifiers across Canada.

Conclusion

The unprecedented interest in virtual care catalysed by the advent of the COVID-19 pandemic has prompted a focus on health equity that is long overdue. Digital health technology is not a panacea; it has the capacity to amplify or reduce pre-existing inequities in health service, depending on how it is deployed and supported. To assure that digital health technology optimizes equity of health services, clear parameters of quality-based design must be established based on evidence and best practice.

Explicit in the commitment to provide equitable health services is an obligation to assure an absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. In the Canadian context, this means that irrespective of one's location within the federation, language, or cultural tradition, one can benefit from access to equitable levels of health services.

"[Digital Health Equity is] essential for our success and the sustainability of digital health overall."

-- Dr. Jorge Rodriguez (Health Technology Equity Researcher and Hospitalist at Brigham and Women's Hospital Department of General Internal Medicine.)

It is very challenging to promote equity of virtual care service if the policy and technology parameters that support equity are not defined, endorsed and broadly applied in practice. Unfortunately, this is the current practice in Canada, where - however well intentioned- a fragmented approach to virtual care design has been the norm, promoting broad variation in system architecture, capacity and service provision, and potentially amplifying health inequities. There is a high likelihood that the virtual care service available to an individual living in one location in Canada will differ substantially from that in another location as the service design is not based on any evidence-based standards of quality of care, including equity.

The Equity Task Team has set out to define high-level principles for virtual care equity that can serve as a benchmark of excellence for virtual care system design. The design principles form an aspirational policy suite that informs equity-based design, and can serve as common ground; a point of reference around which constituent members of the federation can meet to frame and align their approaches to digital health equity. Alignment of virtual care policy around a common goal will promote a unifying approach to service design and deployment, economies of scale, and equity and transportability of virtual care services.

To this end, the central recommendation of this report is the creation of a pan-Canadian Digital Health Equity Working Group that leads and coordinates the implementation of recommendations under five thematic areas: a pan-Canadian vision for digital health equity, patient and caregiver-centered virtual care design, digital health literacy for providers, infrastructure and virtual care technology, and data collection for continuous improvement. Without a broad health service commitment to defined and consensual principles of equitable care, health equity will remain a theoretical artifact rather than a practical reality.

Annex A: List of expert presentations

Update from Canadian Institute for Health Information, Canada Health Infoway, and the Institute for Health System Solutions and Virtual Care at Women's College Hospital on their work relating to equity:

Presentation on Virtual Care in Medical School Curriculum:

Presentation on Culturally-Safe Virtual Care:

Presentation on Digital Health Equity from a Rural Lens:

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