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Virtual care policy framework

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Organization: Health Canada

Published: 2022-03-31

A product of the Federal, Provincial and Territorial Virtual Care/ Digital Table
July 7, 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

Context

  • Driven by the COVID-19 pandemic, provinces and territories (PTs) moved quickly to deploy virtual capabilities for health care so that Canadians could continue to safely access services. By April 2020, about 60% of health care visits in Canada were virtual, compared to 10-20% in 2019. While these changes significantly enhanced access to services during COVID-19, these new virtual care tools were often implemented as temporary/stop-gap solutions, and were not integrated into provider workflows or designed with the patient experience in mind. In addition, PTs were implementing billing codes on a temporary basis only for provider reimbursement of virtual care services. By August 2020, the percentage of virtual visits in Canada had declined to 40%; however, variation exists amongst PTs.
  • Since March, federal, provincial and territorial (FPT) governments have been working collectively to accelerate efforts on virtual care through a focus on three main areas of work:
    • Funding to PTs through bilateral agreements and support by Canada Health Infoway, with shared priorities for technology and infrastructure - In May 2020, the FPT Conference of Deputy Ministers agreed to five shared priorities for technologies and infrastructure, supported by federal investments of $200M. These priorities include secure messaging and information-sharing; secure video-conferencing; remote patient monitoring (RPM); patient access to test results; and back-end supports to enable integration of these new tools into existing digital systems. PTs are currently developing new or enhanced initiatives in virtual care, and FPT officials have recently agreed to a high-level plan for areas of focus for Canada Health Infoway (Infoway) to support efforts in moving forward.
    • Evaluation of impact of virtual care - Shared interest in evaluation to assess the impact of virtual services to improve patient care and outcomes, as well as the efficiency and sustainability of care. The Centre for Digital Health Evaluation (CDHE), Women's College Hospital will work in partnership with Infoway, the Canadian Institute for Health Information (CIHI), and the Canadian Agency for Drugs and Technologies in Health (CADTH) to lead work to support interested PTs to: conduct evaluations of new digital health investments; establish a pan-Canadian approach through a digital health evaluation framework; and create a network to facilitate knowledge translation and accelerate PT capacity in digital health.
    • Policy supports for virtual care - The development of an FPT policy framework, which identifies barriers and opportunities for longer-term adoption of virtual services within Canadian health systems.
  • This work on virtual care is laying the ground for a more permanent shift to virtual services as an additional channel for access that complements traditional face-to-face models of care. The policy framework will identify the appropriate enablers of virtual service delivery as a component of health care within Canadian health systems. The policy framework will also be critical to ensuring that governments are well-positioned to address/avoid unintended consequences arising from the widespread uptake and use of virtual care (e.g., addressing incentive structures to ensure appropriate mix of virtual and face-to-face visits; ensuring access to in-person care for rural, remote and underserved urban areas; and implementing measures to enable equity of access for vulnerable populations).

Overall purpose of the policy framework:

  • Identify the key policy enablers and supports to allow for sustainable use of virtual care technologies in Canada in keeping with shared goals and outcomes. Recognizing that these policy enablers are within PT jurisdiction, this framework aims to reach a shared pan-Canadian view of the enablers that will best drive change, with a view to supporting subsequent work to map out a shared strategy for concerted efforts across willing jurisdictions supported by key organizations and stakeholders, and by the federal government. The ultimate goal is to lay the ground for action on a shared FPT strategy to ensure that virtual care can be a facet of strong, efficient and sustainable publicly funded health systems in Canada.

Goals and desired outcomes:

  • Virtual care should advance the principles of the quadruple aim by: improving patient experience, quality of care and health outcomes; strengthening population health outcomes; delivering better value in the delivery of care; and, improving provider experience in the delivery of care.
  • Based on these broad principles, the goals and desired outcomes of virtual care work is to:
    • Enhance access to care - Better integration of virtual care services and tools within the health system could enhance patient access to care at home and in the community as part of publicly funded health services. It could also serve as a tool to improve equitable access for Indigenous, vulnerable and remote/rural populations, so long as barriers related to digital literacy and affordable, reliable access to broadband are addressed
    • Provide high-quality, appropriate and safe care - Virtual care provides an opportunity to deliver high-quality, patient-centred and appropriate care. Virtual service delivery could significantly improve the continuity and coordination of care.
    • Protect and strengthen the publicly funded health care system - Patients should continue to have access to physician and physician-equivalent services without having to face patient charges, regardless of whether these services are received virtually or in-person.
    • Improve patient and provider experience of care - Virtual care offers a complementary avenue for the delivery of care, through multiple modalities, which has the potential to provide more accessible and convenient care for patients, and offers the potential for better collaboration between providers supported by virtual/digital tools.
    • Improve health system efficiency - The policy enablers should consider virtual care through a value lens so that it is introduced and deployed in a manner that supports appropriate returns on investment and health system sustainability.

Areas of focus

  • In order to deliver on the above goals and desired outcomes, the framework identifies the following policy pillars to enable the longer-term adoption of virtual care, while also respecting jurisdictional differences and priorities:
    • Patient and community centred approaches provide the paradigm for virtual care as a channel of care.
    • Equity in access to virtual care services will help to ensure that all Canadians are able to fully take advantage of and benefit from the adoption/use of virtual care in Canadian health systems as part of publicly insured health services, including with respect to connectivity and broadband.
    • Remuneration/compensation is a key enabler of virtual care and it will be important to explore how to design remuneration models to ensure patient-centred and high-quality care, and support sustainability of the health care system over the longer-term.
    • Change management (e.g., training, integration of virtual care tools with existing clinical practice and workflows) is a critical enabler to ensure the adoption and effective use of virtual care by organizations and providers.
    • Appropriateness, safety and quality of services is important to ensure that virtual care is appropriate and safe for the condition being treated and that patients receive high-quality care.
    • Licensure is a critical enabler of facilitating the delivery of virtual care across jurisdictional boundaries.

Policy foundations

  • Foundational work, underpinning all policy pillars, is needed on:
    • Privacy and security;
    • Data standards and integration; and
    • Technology (procurement, standards, and operation).

These interconnected elements are the essential enablers to sharing patient information across digital technologies. A permanent shift toward accessing virtual services will not only require the appropriate technology, but also the secure collection and storage of interoperable patient information. This will inform policy directions, ensure successful management of health care programs, and maintain/enhance health care quality, effectiveness and patient experiences.

Approach to the work

  • Recognizing that the policy pillars fall largely within provincial and territorial and clinical practice domains, the suggested approach aims to provide value by supporting and integrating current efforts across different policy enablers by:
    • Exploring ongoing work and opportunities for greater synergies;
    • Sharing best practices/new approaches/ lessons learned;
    • Leveraging what is already in place or being built across Canada;
    • Adopting pan-Canadian approaches to make progress on common challenges, while respecting jurisdictional priorities and needs; and
    • Considering role of federal levers, pan-Canadian levers, strategic partnerships and other efforts to amplify and accelerate work.
  • The policy framework, focus and pillars will recognize the value of cross-jurisdictional and pan-Canadian approaches (e.g., to advance common approaches to licensure), while being sensitive to and reflecting on unique individual provincial and territorial circumstances and priorities.
  • Patients will play an integral role in the development of the policy framework to ensure that work on each of the policy enablers aligns with the goal of enhancing patient-centred care that improves patient experience and outcomes.
  • As a first step, given the interconnected nature of this work, consideration will be needed on the most appropriate sequencing of the proposed work on the policy pillars. For example, gaining insights on when virtual care is most appropriate could be a foundational element to other strands of work, such as remuneration.

Forward plan

Diagnostique

  • Development of overarching diagnostique on the policy enablers, which will validate the framing of the pillars and then include an analysis of the state of play on each pillar, as well as the policy enablers as a whole.
    • The attached chart below provides an initial overview of the pillars, objectives for collective action within each of them as policy enablers for virtual care, and mechanisms and opportunities that could be leveraged to support change.
  • The diagnostique will involve scanning/mapping of activities within Canada (i.e., PT initiatives, FPT initiatives, and work of stakeholders such as the Canadian Medical Association (CMA), regulators and others) on each of the following priority areas to assess what activities are underway and consider opportunities for strategic partnerships, as well as for best practices and shared approaches. Specifically, it will include:
    • Analysis, objectives and desired policy outcomes for work in each of the pillars, as well as analysis of overarching objectives and needs related to the policy enablers as a whole, including sequencing of the work under the pillars for maximum impact;
    • Scanning/mapping of ongoing and planned activities across a range of partners/stakeholders;
    • Identification of gaps/challenges, cross-jurisdictional issues/needs, and the potential for strategic partnerships;
    • Identification of federal levers (such as the federal privacy commissioner, the Canada Health Act), FPT levers (such as the pan-Canadian health organizations (PCHOs) or FPT committees) and other mechanisms that could support work on priorities;
    • Assessment of opportunities and interest for collective action supported by federal/pan-Canadian/other levers and activities along with proposed sequencing of the work for greatest impact; and
    • Recommendations for a collective strategy for action.
  • As part of this work, the diagnostique will consider the role of all relevant partners and stakeholders, and will also consider the role of patients as a driving force to inform and shape the strategy and enable progress on work across the pillars.
  • The FPT Expert Working Group will be asked to review the work on an ongoing basis and provide input and advice on an as needed basis.

At critical junctures of the work, the FPT Virtual Care/Digital Table will also be asked to provide oversight and direction on the diagnostique.

Summit to co-create strategy for action

  • Following development of diagnostique, convene key partners and leaders across relevant groups for a summit to discuss and shape a strategy for moving forward:
    • Key leaders across a broad range of interested groups would discuss synergies, potential forward approaches, and opportunities for strategic partnerships.
    • Objective would be to co-create a shared strategy for moving forward, using a broad range of levers across relevant stakeholder groups and governments.
Specific approach by policy pillars
Policy pillars Objectives
and scope of work		 Existing mechanisms or opportunities Forward approach
Patient and community centred approaches
  • To support PTs integrate patient and community centred approaches in the design and delivery of virtual care.
  • This would include exploring best practices in meaningful patient and community engagement to manage expectations around a range of issues (e.g., access, quality, privacy, etc.), with a view to building trust and ensuring virtual care services are designed from a patient and community centred perspective.
  • This work would also include engagement with patients and communities, including vulnerable and underrepresented populations (such as Indigenous communities) to explore the role of patients in designing virtual care that is culturally safe and aligned with principles of trauma informed care.
  • Explore approaches to enhance digital health literacy for patients so that they are better prepared to fully take advantage of virtual tools.
  • Patient groups
  • Provider organizations - Canadian Medical Association (CMA), Canadian Nurses Association (CNA)
  • Potential role for PCHOs with strong patient focus (i.e., Canadian Patient Safety Institute (CPSI)/Canadian Foundation for Healthcare Improvement (CFHI))
  • Consider role of CPSI/CFHI in leveraging patient networks to explore how to engage patients in the design of virtual care
  • Assess best practices in patient and community engagement
Equity in access to care
  • To identify barriers and obstacles to equitable access to virtual care health services for a broad range of vulnerable and underrepresented groups (e.g., rural and remote populations, Indigenous peoples, racial/ethnic minorities), with a view to developing pan-Canadian approaches to address barriers to access.
  • As part of this work, consider digital disparities and the need for greater equity of access to affordable broadband across Canada, which will be critical to ensure that rural and remote populations and others can use virtual care services.
  • In addition, a critical component of this work will be to design the widespread adoption and use of virtual care to help strengthen and enhance Canadian publicly funded health systems by ensuring that Canadians have access to virtual care services without facing patient charges.
  • National Research Council (NRC) work on accessibility standards for virtual care tools.
  • Other federal departments, i.e., Indigenous Services Canada (ISC), Canadian Heritage (PCH), Innovation, Science, and Economic Development Canada (ISED)
  • A subcommittee of the Expert Working group is developing a framework for equitable access to virtual care and to 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
Provider remuneration/incentive structures Footnote i, Footnote ii
  • To support work within PTs on identifying approaches to remuneration that allow for quality patient care via virtual services as one channel for delivery.
  • Immediate focus on secure messaging and information sharing; video-conferencing; and, remote-patient monitoring.
  • This work could include looking at issues and best practices around the "right-sizing" and design of payment models (e.g., should all types of virtual care be compensated the same, and should all virtual care services be compensated at parity with face-to-face visits?).
  • To consider reciprocal billing issues as they relate to possibility of increased delivery of virtual care services across jurisdictional borders
  • To consider how to address emergence of virtual walk-in clinics, including appropriate payment models and how to integrate within health systems for coordinated and integrated care.
  • Link with work on change management and role of team-based care; potential longer-term work delegation of authority.
  • FPT Committee on Health Workforce (CHW)
  • CMA
  • Interprovincial Health Insurance Agreements Coordinating Committee (IHIACC)
  • PT mechanisms (BC Medical Services Commission, SK pilot project)
  • Stakeholder work (CMA)
  • International work
  • Leverage existing work:
  • CHW sub-committee on physician remuneration work on principles to inform remuneration decisions
  • Some provinces actively working on approach
  • Engagement with external organizations (CMA, medical associations) to explore common priorities and potential approaches
  • Opportunities to share best practices
  • Opportunities to leverage existing bodies such as IHIACC on reciprocal billing issues
Appropriate-ness, safety and quality of care
  • Understand current state of clinician-led and PT work on appropriateness and quality of care.
  • Explore opportunities for synergies/support across jurisdictions with federal support to address challenges related to appropriateness, safety and quality of care for virtual care services, including current virtual walk-in clinic model.
  • Understand and avoid unintended consequences, as discussed at the FPT Committee on Health Workforce (CHW), such as appropriate mix of virtual and in-person care, and to avoid potential reduction in access to in-person care particularly for rural, remote and underserved urban areas. This work would include ensuring that virtual care services are a key component in the suite of publicly insured health services.
  • Professional regulatory bodies, i.e., Federation of Medical Regulatory Authorities (FMRAC)
  • Provider organizations - CMA, CNA
  • PCHOs

Appropriateness and quality of virtual care services

  • Opportunity to leverage jurisdictional work, e.g., AB has set up a new working group that brings together a range of perspectives (e.g., pharmacists, physicians, Indigenous, etc.) to develop quality-based design of virtual care.
  • Leverage work of the professional regulatory bodies in this area

Appropriate role of virtual walk-in clinics

  • Opportunity to launch a targeted research project (led by PCHO or academic/ researcher?) that explores the current state, value and appropriate role of virtual care walk-in models
Provider change management
  • Unpack and understand scope of need related to change management (e.g., clinical workflow redesign; new models of care; clinical role changes; provider digital literacy; clinician change management).
  • Identify best practices and strategies at organizational and provider levels.
  • Consider vendor supports for change management and other approaches.
  • Identify best practices to implement and sustain virtual care approaches in existing clinical practice and workflows.
  • CFHI
  • Infoway
  • Provider associations - CMA/CNA
  • Regulatory bodies
  • Scope impact of technologies such as remote patient monitoring in terms of changing approaches/models of care
  • Current state analysis of challenges and gaps, including assessing degree of vendor support for new products, and availability of technological supports
  • Assess best practices, including provincial digital health teams or centres of excellences
Licensure Footnote iii
  • To support PT and stakeholder efforts on developing common approaches to licensure, with exploring pan-Canadian licensure for virtual care as a potential first step/pilot.
  • Link to remuneration/ payment work on reciprocal billing given that common approaches to licensure could result in increased delivery of services across jurisdictional boundaries.
  • To support PT and stakeholder efforts on developing common approaches to a pan-Canadian registration system, through which all physicians are assigned a unique identifier and included in a pan-Canadian physician registry, with a view to facilitating pan-Canadian licensure.
  • CHW
  • Professional regulatory bodies - College of Family Physicians of Canada (CFPC); Royal College;
  • Engagement with FMRAC, which has an active telehealth working group and is looking at issues related to licensure
  • Provider groups - CMA
  • Leverage existing work being led by CHW
  • Consider role of professional regulatory bodies along with provider groups (e.g., CMA)
Footnote i

Limiting to our immediate areas of focus has value by scoping what is a huge issue. The question is whether this is realistic, or whether the remuneration issues are too complex for such a focus.

Return to footnote i referrer

Footnote ii

Alternative approaches could involve considering specific sectors or clinical areas, e.g., primary care, or cardiac care.

Return to footnote ii referrer

Footnote iii

With respect to pan-Canadian physician registry, Medical Information Numbers for Canada (MINC) exist for most physicians. However, the policy gap is the absence of a national database. A first step in addressing this gap could be exploring standards for that data.

Return to footnote iii referrer

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