Submission by Canadian Medical Association

September 17, 2020

To whom this may concern:

On behalf of the Canadian Medical Association (CMA), please find attached some preliminary comments on the four discussion questions regarding your proposed market study on digital health. I would note at the outset that in 2019 the CMA convened a Virtual Care task Force (VCTF) jointly with the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada, and it included members from national and provincial medical organizations as well as patient representatives. The Task Force addressed four critical issues that must be addressed in order to enable the widespread uptake of virtual health care in Canada:

• Interoperability & governance;
• Licensure and quality of care;
• Payment models; and
• Medical education.

The VCTF released its report on February 11, 2020 and it sets out 19 recommendations that touch on most of the issues identified in your questions. As you are doubtless aware, the COVID-19 pandemic has hastened the uptake of virtual medical care in every jurisdiction, and this will be noted on the comments that follow.

1. To begin with, choice is generally a good thing, but in the health field, and primary care in particular, it should be tempered with consideration to continuity of care. Two of the critical dimensions are relational continuity – such as with a family physician/health team over a period of time, and informational continuity – the ability to access/integrate all of the relevant information about the patient’s medical history across the delivery points in the health care system. There has been considerable innovation in the past few years, particularly in the private sector, to introduce virtual care services that can be delivered 24/7 in the comfort and convenience of the patient’s home, as well as to make health care available to persons who do not have a regular provider of non-urgent care. However, there is the potential for virtual care, if it is not integrated with the patient’s regular provider and health record, to fragment continuity of care and this should be taken into consideration. As for the issues of rules that unnecessarily impact the ability to offer virtual products and services this will be addressed in the answer to question 2.

2. As discussed in depth in the VCTF report and in a 2019 CMA discussion paper on virtual care there are barriers to accessing virtual care.

   Interoperability – the ability to exchange health care information electronically across the system. This would be a particularly worthy topic of the Competition Bureau’s investigation because there are some key unanswered questions:

   • To what extent is/can health information be shared across publicly funded health care settings including physician offices, hospitals, home care and long-term care and what are the limiting factors – is it an issue of technical standards or policies?
   • To what extent is health information held in proprietary databases (e.g. private sector) that are not interoperable?
   • To what extent does privacy legislation prohibit the exchange of health information across delivery points and jurisdictional boundaries?

   This topic would merit an in-depth investigation.

   Payment models for medical care – since the pandemic began all jurisdictions have put in place billing mechanisms for virtual care by videoconference. However, the experience of Kaiser Permanente in the U.S. shows that in 2017 secure email accounted for 26% of all patient touches. Clearly there is great potential for the use of asynchronous means of communication. Another aspect of this is that with few exceptions, virtual care cannot be billed unless the physician provides it personally.

   Licensure – most jurisdictions require that a physician providing virtual care to hold a license to serve a patient located in that province. Even where this is not required there is the additional issue of a physician billing number that permits the patient to gain publicly-paid lab and diagnostic resources in the patient’s jurisdiction. The Federation of Medical Authorities of Canada is working on three initiatives to enhance physician mobility and these are described in the VCTF report.

   Access Barriers – there remains a digital divide in Canada with respect to broadband. The most recent information posted on the CRTC website indicates that while overall 86% of Canadians have access to broadband speed of 50/10 Mbps, just 41% of those in rural communities do. There is also a socio-economic gradient to access to the internet that is discussed in the VCTF report.

3. The VCTF did not do a thorough international scan of virtual care. However, earlier this year the OECD published a comprehensive overview of telemedicine across their member countries based on a survey and interviews that were conducted among the majority of members. See Hashiguchi T, Bringing health care to the patient: an overview of the use of telemedicine in OECD countries. OECD Health Working Papers No. 116.

4. COVID-19 has resulted in an extremely rapid uptake of virtual care among physicians and patients alike. The results of a survey conducted on March 30^th by the CMA among the practising physician population showed that 75% of physicians were providing virtual care by at least one means. These included:

   • Telelihone 75%
   • Videoconferencing 32%
   • Secure email/text messaging 18%
   • Remote liatient monitoring 6%.

Regarding the experience of patients, the CMA commissioned a public survey by Abacus Data in May of this year. This survey showed that virtual visits outnumbered in-person visits by a large majority. For example, among those who reported they needed advice since the pandemic began, 34% indicated that they had obtained it by telephone with their doctor, while just 10% indicated it was through an in-person visit. The findings also reflected the lower frequency of use of videoconferencing and text/email reported by physicians, with just 6% and 4% of patients having used these means respectively. As noted above, this is a reflection of the way that payment models have been introduced. Patients expressed high satisfaction with virtual care.

In closing I look forward to seeing the preliminary findings report of this consultation.

Sincerely,

Timothy R. Smith, B.S.Sc., MBA, ICD.D
CEO, CMA Group of Companies