Canada-Newfoundland and Labrador Virtual Care Bilateral Agreement: Action plan

Introduction

Virtual care can be defined as any interaction between patients and/or members of their circle of care, occurring remotely, using any form of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care.

Virtual care has played an important role in improving the delivery of equitable health services to citizens of Newfoundland and Labrador for more than thirty years. However, never has it experienced the uptake and expansion since the emergence of the COVID-19 global pandemic.

At the onset of the pandemic, delivering and receiving care virtually has proven to be a necessity for health care providers and the citizens of our province. Contributing to the safety and well-being of our population by following public health guidelines, virtual care enables a safe virtual environment with reduced risk of COVID-19 spread. Virtual care has also addressed many other barriers currently faced by Newfoundlanders and Labradorians by offering convenience from access to care in rural/remote areas, avoidance of travel in inclement weather in addition to personal costs and time lost from work often incurred from travelling to appointments.

As the province prepared for rapid change in the delivery of health care due to the COVID-19 pandemic, there was an immediate need to leverage existing virtual care solutions through its well established Provincial Telehealth Program. In addition, the province rapidly deployed a number of other health solutions supporting virtual care to the providers and citizens of Newfoundland and Labrador to ensure an appropriate response to emergent health care needs. Some of the health solutions enabling virtual care that have been rapidly deployed as a result of the COVID-19 pandemic include the following:

• COVID-19 test results: providing citizens with online access to view their negative test results online.
• COVID-19 vaccination booking: providing citizens with online access to schedule appointments for their COVID-19 vaccine.
• COVID-19 testing assessment and referral: providing citizens with online access to a self-assessment and referral
• Expansion of Virtual Care capabilities in priority health care delivery areas:
• Long Term Care (LTC): As visitation restrictions were implemented within LTC facilities across the province, a need for residents to connect with their family and friends virtually was critical. Providing electronic devices to residents over the past year has provided significant value.
• Primary care: Policy enablers such as remuneration for physicians were implemented rapidly to ensure providers and citizens of our province were able to seek primary care while still following public health guidelines.
• Acute care: Virtual care tools were deployed in the Emergency Departments, Intensive Care Units, Quarantine Units, Long Term Care and Personal Care Homes. Leveraging the existing Telehealth platform and other virtual platforms, the province deployed a significant number of new accounts to support these key service delivery areas.

Overview of Virtual Care Action Plan

As the province continues to respond to the rapid change in the health system, the need to incorporate virtual care as part of health care delivery across the continuum of care is evident and a vital step toward digital transformation in the provincial health system. Through the Virtual Care Bilateral Agreement, Newfoundland and Labrador's Action Plan focuses on three key initiatives:

• Expansion, Sustainment and Evaluation of Virtual Care Services
• Establishment of a Provincial Virtual Care Strategy
• Expansion of Virtual Care Health Services

Initiatives under the Bilateral Agreement

Initiative 1: Expansion, sustainment and evaluation of virtual care services
While Newfoundland and Labrador was able to leverage existing virtual care platforms to support the anticipated increased demand, additional supports to scale the existing service offerings into new health care delivery areas across the province required significant investment. As a result, federal funding from this agreement will be used to invest and support virtual care services utilized by the health system today to ensure that service levels, functionality and performance expectations are achieved from a patient, provider and overall health system perspective. Specifically, investments will focus on the expansion and sustainment of the Provincial Telehealth infrastructure and support services in addition to other solutions that enable virtual care across the continuum of care, such as Zoom Healthcare to further support providers in their delivery of care.

Investment in the formal evaluation of the current state of Virtual Care in Newfoundland and Labrador will also be a key priority of this initiative. Adoption, implementation and analysis of a national evaluation framework will be critical in informing the short and long term strategy of virtual care in our province. Aspects of the evaluation will focus on patient and provider experience, clinical outcomes, environmental impacts, cost impacts to the delivery of care and other key criteria highlighted through national evaluation frameworks. Each of these will be imperative to ensure virtual care is making a difference in the lives of our citizens and overall health system. Establishment of key performance indicators will also be included in collaboration with key stakeholders both provincially and nationally to enable evidence based decisions required for policy changes in a rapidly evolving environment.

Initiative 2: Provincial virtual care strategy
In partnership with key stakeholders, this initiative will use federal funding to support the development of a Provincial Virtual Care Strategy. Taking a patient-centered approach, the strategy will enable a sustainable virtual care delivery model that will persist beyond the pandemic. Newfoundland and Labrador has a long history with virtual services due to a large rural population dispersed over a large geographic area. Development of a provincial strategy will ensure greater accessibility of services and will particularly benefit NL's rural and remote populations through reduced wait times, travel time and expenses. Based on shared provincial and territorial principles, key components of the provincial strategy will aim to include, but not limited to:

• Patient benefits and experience;
• Provider expectations and experience;
• Patient and community centered approaches;
• Change management;
• Privacy and security;
• Interoperability and data standards.

Key engagement and consultation with provincial stakeholders, including indigenous partners and federal funding agencies (e.g. Health Canada, Canada Health Infoway) will be critical to ensure the Newfoundland and Labrador Virtual Care Strategy is robust and properly informed.

Initiative 3: Enhancing virtual care health services
This initiative will use federal funding to support a holistic assessment of the province's digital health ecosystem that enable and support virtual care in alignment with the priorities identified as part of the newly defined provincial strategy. Expanding on the COVID-19 Results Patient Portal for example will focus on providing citizens with further access to their health information and virtual care services. Federal funding will be used to invest in data interoperability and end user validation services needed to provide citizens with access to lab results, medications and immunizations including COVID-19. This will help to advance the evolution of a provincial Personal Health Record (PHR) further supporting the needs of our citizens to enhance the overall management of care.

Electronic Consultation Services (eConsult) will also be enhanced to further support the reduction of travel for patients (especially those who reside in rural/remote communities) and potentially reduce wait times for specialty care, the eConsult solution was migrated to a new, more robust and modern platform. This tool provides health care providers the ability to effectively communicate in a timely, secure manner creating system efficiencies through direct integration of the Provincial Electronic Health Record (EHR) and Electronic Medical Record (EMR). Federal funding will also be used to equip a dozen virtual ERs throughout the province to support patients living in rural and remote communities with limited access to services. As well, it will facilitate enhanced virtual mental health supports through investment in equipment for Mental Health and Addictions Counsellors.

Through the development of the Provincial Virtual Care Strategy, expansion and improvement of services such as virtual visits, secure messaging and remote patient monitoring will also be assessed.

Funding allocation

Virtual Care Bilateral Agreement Funding support allocation

Initiatives	2020-21	2021-22	2022-23	Total
Expansion, sustainment and evaluation of virtual care services	$116,000	$1,054,851	$504,000	$1,674,851
Provincial virtual care strategy			$200,000	$200,000
Enhancing virtual care services		$2,058,945	$606,303	$2,665,248
Total	$116,000	$3,113,796	$1,310,303	$4,540,099

To further support the goals and objectives outlined in Newfoundland and Labrador's bilateral federal agreement, Canada Health Infoway (Infoway) will invest up to $2M as part of a national Virtual Care Investment Program to accelerate jurisdictional efforts in the deployment of virtual care solutions. The province will work closely with Infoway to identify key initiatives aligning to the following project goals or range of solutions:

• Increased access to citizen facing solutions such as patient portals, online appointment booking solutions and remote patient monitoring;
• Expansion of virtual visit and provider-to-provider solutions including hardware and infrastructure, to support increased adoption and uptake;
• Improved integration of virtual care solutions with existing clinical systems and decision-support tools;
• Implementation of interoperability specifications to support testing environments and support interoperable API development; and/or
• Increased human resource support for PTs from Infoway to execute the project implementation lifecycle in the areas of strategic planning, project management, change management, architecture, privacy and security and project evaluation.

Expected results

In partnership with key national and provincial partners, NL will develop a benefits evaluation and key metrics for each of the three initiatives outlined in this action plan.

NL will also work collaboratively with the Canadian Institute of Health Information (CIHI) to identify a set of pan-Canadian indicators and provide jurisdiction specific baseline data that will be used by CIHI to measure progress on virtual care implementation; where possible and appropriate this will also include disaggregated data (e.g. broken down by age group, gender, etc.).

Summary of indicators and expected results

Initiatives	Outputs	Target outcome
Expansion, sustainment and evaluation of virtual care services	Virtual care evaluation framework Development of standardized intake processes for virtual care services Key performance indicators focused on quality, safety and appropriateness Provincial privacy and security framework for virtual care	Demonstrate increase in number of patients accessing virtual care tools and services Demonstrate increase in virtual care services to additional health care delivery sites Demonstrate positive patient experience using virtual care tools and services Enhanced Coordination of Virtual Care Services Implementation of privacy and security measures relating to process and technology
Development of a provincial virtual care strategy	Provincial Virtual Care Strategy Governance Model Policy recommendations to enable virtual care Virtual Care Maturity Model Framework Adoption	Provincial alignment through strong collaborative governing structure Development of a collaborative approach with engagement from distinct stakeholder groups on virtual care policy and service delivery enablers Virtual Care Priorities defined at the Provincial Level
Expansion of virtual care health services	Patient experience and satisfaction by target audience Expansion of eConsult capabilities to priority service areas Expansion of Citizen Access to health records	Improved access to online tools and services by target audience Demonstrate that virtual care when combined with traditional models of care can improve access, safety and patient experience Improved patient empowerment through health record access Modernization of end user management resulting in a secure and robust identity management process