Telehealth and Virtual Care

The availability of virtual clinics in Canada and worldwide has increased in recent years, the COVID-19 pandemic particularly contributing to the increased demand and provision of virtual care (i.e., medical care delivered at a distance by means of technology). The rise of virtual care during this pandemic has been viewed by many as a silver lining. It is this jump in advancement and adoption of technology that may help drive decarbonization pathways and sustainability in healthcare. PEACH Health Ontario promotes putting a “green spin” on the use of virtual health and health information technology, with a focus on pathways that can be implemented today and scaled to even greater mitigation ambition in the longer term.

Did you know? Research has shown that the proportion of physicians in Ontario who provided virtual care increased from 7 per cent in 2019 (the pre pandemic period) to 85.9 per cent in 2020 (during the pandemic) [1]. The rates of virtual care use increased across all age groups. Patients with psychiatric disorders had the highest rate of virtual visits, followed by those with heart failure, chronic obstructive pulmonary disease, angina, diabetes mellitus, hypertension and asthma [1].

Virtual Care – What Lessons Have Been Learned?

Healthcare providers have long advocated for the advantages of telehealth use in reducing travel and costs associated with it, particularly regarding the decrease in carbon intensity [2]. In a 2010 article by Yellowlees et al. [3], the authors argued that the healthcare sector in North America was generally lacking environmentally sustainable practices. Fast forward a decade later, there is still a great deal of work for the healthcare sector to make a greener stance. By implementing green practices, the healthcare sector could benefit financially, as well as reduce its negative impact on the health of people and the planet. Virtual care and health information technology can save energy, fuel and raw materials (e.g., paper, plastic) and thus reduce the carbon footprint of the healthcare sector [3].

In recent years, the American Telemedicine Association launched a task force to study how the use of telehealth and telemedicine may be affecting climate change and global warming [4]. In 2017, this task force addressed that matter; researchers at a U.S. university found that telehealth and telemedicine programs saved patients and clinicians 5 million miles of travel over 18 years, equal to about nine years in travel time and $3 million in costs, and helped their academic location to reduce nearly 2,000 metric tons of carbon dioxide (CO2), 50 metric tons of carbon monoxide, 3.7 metric tons of nitrogen oxides, and 5.5 metric tons of volatile organic compounds [4].A recent U.S. study examining the reduction in greenhouse gas emissions from transportation to outpatient clinic visits showed that emissions rose from 18.5 to 19.6 (in 2019) before declining to 10.5 kilotons CO2-equivalent in 2020 [2]. In this same study, ambulatory visit carbon intensity declined from 8 to 4 kg CO2-equivalent per visit over the same time period [2]. If clinicians were to maintain those gains or expand upon in the post-pandemic world, further impacts on practice design could potentially contribute to even greater reductions in greenhouse gas emissions. Thus, providing telehealth virtual visits can be one tool to fight climate change.

However, sustainability measures are evidently needed. There is a need to develop robust, standardized metrics to define environmental performance and evaluate progress if the healthcare sector is to meaningfully embark on reducing its environmental impacts. Patients, clinicians, and medical leaders need adequate information in order to maximize the environmental benefits of online and virtual care. A 2019 Canadian Medical Association report [5], The Future of Connected Health Care, outlined that Canadians were already ready for the healthcare sector to modernize and match the online experience they were getting from other sectors. In this vein, Ontario announced in 2019 its Digital First for Health strategy to support an inclusion of virtual care [6]. In 2020, a Virtual Care Task Force (VCTF) was created by the Royal College of Physicians and Surgeons of Canada, the College of Family Physicians of Canada, and the Canadian Medical Association to set the stage for broader discussion and more detailed efforts [7]. This VCTF took a pan-Canadian approach to the issue of virtual care and strongly believed that national leadership was needed on this issue. The VCTF report outlined the actions required to promote excellence in virtual care in Canada.

In order to ensure a more sustainable development, we believe that it is important for educational programs, such as MD programs, other graduate level professional training programs, and graduate medical education programs, to actively integrate mastery of technological advances into training programs. In order to keep up the pace with increasing awareness and adoption of new emerging technologies into clinical practice, some have proposed the conception and implementation of an academic technology division within medical departments. Such division can be tasked with educating both physicians-in-training and practicing physicians about integration of technology acceptance models, as well as integration of emerging digital technologies [8]. Encouraging medical departments to partner with departments of computer science and other technical fields can only foster collaborative opportunities for greater and greener sustainability of medicine.

The healthcare sector must seize the opportunity to modernize and promote the health of the people as well as the planet, because these two issues are ultimately interconnected. Physicians and other clinicians need to raise awareness and educate patients and communities about climate-sensitive health risks, which will go a long way. If there is a considerably growing public demand for virtual care that has a positive influence on both human and planetary health, then we are hopefully going to make good decisions for a successful path to sustainable medicine. The PEACH Health Ontario team aims to make the environmental health benefits of virtual care more widely known so that health systems and societies can adjust and thrive in the “new normal” of the post-pandemic world.

In practice

The PEACH Health Ontario team aims to:

• Scientifically review the current literature on telehealth and virtual care and work to identify effective strategies developed locally and worldwide to help with decarbonization as a realistic way forward on climate change mitigation
• Make recommendations on a set of strategies and tools that can be disseminated for generalized use across institutions to provide meaningful information on the carbon footprint implications of innovative virtual care modalities
• Disseminate information on national standards for privacy and security considerations for virtual health care visits
• Suggest that the CanMEDS Consortium continues to update virtual learning competencies for the undergraduate, postgraduate and fellowship programs, as well as to promote the continuing professional development (CPD) endeavours through integration of emerging technology-based virtual health strategies

References

1. Bhatia RS, Chu C, Pang A, Tadrous M, Stamenova V, Cram P. Virtual care use before and during the COVID-19 pandemic: A repeated cross-sectional study. CMAJ Open. 2021;9(1):E107-E114. doi: 10.9778/cmajo.20200311. PMID: 33597307; PMCID: PMC8034297.
2. Dacones I, Cave C, Furie GL, Ogden CA, Slutzman JE. Patient transport greenhouse gas emissions from outpatient care at an integrated health care system in the Northwestern United States, 2015-2020. The Journal of Climate Change and Health. 2021;3:100024. https://doi.org/10.1016/j.joclim.2021.100024.
3. Yellowlees PM, Chorba K, Burke Parish M, Wynn-Jones H, Nafiz N. Telemedicine and e-Health. 2010;16(2).229-232. http://doi.org/10.1089/tmj.2009.0105.
4. Wicklund E. American Telemedicine Association. ATA Task Force to Study Environmental Effects of Telemedicine. June 21, 2017. https://mhealthintelligence.com/news/ata-task-force-to-study-environmental-effects-of-telemedicine. Accessed January 15, 2022.
5. Canadian Medical Association (CMA). The Future of Connected Health Care. Reporting Canadians’ Perspectives on the Health Care System. August 2019. https://www.cma.ca/sites/default/files/pdf/Media-Releases/The-Future-of-Connected-Healthcare-e.pdf (PDF). Accessed January 15, 2022.
6. Government of Canada. Ontario’s virtual care streamlined action plan. Last modified: June 18, 2021.
   https://www.canada.ca/en/health-canada/corporate/transparency/health-agreements/bilateral-agreement-pan-canadian-virtual-care-priorities-covid-19/action-plan-ontario.html. Accessed January 15, 2022.
7. Royal College of Physicians and Surgeons of Canada (RCPSC). Virtual care. https://www.royalcollege.ca/en/health-policy/virtual-care-task-force.html. Accessed May 28, 2024.
8. Hategan A, Giroux C, Bourgeois JA. Digital technology adoption in psychiatric care: An overview of the contemporary shift from technology to opportunity. Journal of Technology in Behavioral Science. 2019;4(3):171-177. https://doi.org/10.1007/s41347-019-00086-x.

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This page will be updated regularly with up-to-date information about this important initiative.