On this episode, Drs. Blair Bigham and Mojola Omole delve into the evolution and advancements in virtual urgent care since the COVID-19 pandemic. The discussion centers around the study published in CMAJ entitled "Healthcare utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care," which analyzed patient usage and outcomes during the height of the pandemic.
The study didn’t specifically track how many patients were redirected from emergency departments (ED) to virtual care. However, it found that around 80% of patients seen via virtual urgent care didn't require an immediate ED visit, suggesting that virtual care likely reduced some emergency presentations. However, it also noted that virtual urgent care didn't always prevent subsequent hospital visits. Importantly, the study reflects a specific period and doesn't capture the current state of virtual urgent care.
Dr. Justin Hall, director of the Toronto Health Region's Virtual Urgent Care Program, describes how the service has developed since 2020. Key improvements include enhanced technology for a more seamless patient experience and additional capabilities like imaging and laboratory testing. Dr. Hall says the program now acts as a crucial link for patients without regular access to healthcare providers and can successfully address acute, non-life-threatening conditions.
Drs. Bigham and Omole then speak with Mary Dimeo, a nurse practitioner working in the Toronto region's virtual urgent care service. She describes her role and experiences in the virtual environment. Ms. Dimeo says, typically only one patient per day needs to be referred to the emergency department which suggests the service helps divert patients from the hospital, especially those without family doctors or who cannot wait for an appointment.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
On this episode, Drs. Blair Bigham and Mojola Omole delve into the evolution and advancements in virtual urgent care since the COVID-19 pandemic. The discussion centers around the study published in CMAJ entitled "Healthcare utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care," which analyzed patient usage and outcomes during the height of the pandemic.
The study didn’t specifically track how many patients were redirected from emergency departments (ED) to virtual care. However, it found that around 80% of patients seen via virtual urgent care didn't require an immediate ED visit, suggesting that virtual care likely reduced some emergency presentations. However, it also noted that virtual urgent care didn't always prevent subsequent hospital visits. Importantly, the study reflects a specific period and doesn't capture the current state of virtual urgent care.
Dr. Justin Hall, director of the Toronto Health Region's Virtual Urgent Care Program, describes how the service has developed since 2020. Key improvements include enhanced technology for a more seamless patient experience and additional capabilities like imaging and laboratory testing. Dr. Hall says the program now acts as a crucial link for patients without regular access to healthcare providers and can successfully address acute, non-life-threatening conditions.
Drs. Bigham and Omole then speak with Mary Dimeo, a nurse practitioner working in the Toronto region's virtual urgent care service. She describes her role and experiences in the virtual environment. Ms. Dimeo says, typically only one patient per day needs to be referred to the emergency department which suggests the service helps divert patients from the hospital, especially those without family doctors or who cannot wait for an appointment.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. And this is the CMAJ Podcast. So today, Blair, we're looking at a paper called, “Healthcare utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care.” And so this is a prospective study that took place September of 2020, and they collected data to December of 2021. It's a really interesting paper because it's a snapshot in time when the pandemic was at its height and we were trying to figure out how to best serve people but limit inpatient contact, whether to family physician's office, but also to the emergency department.
Dr. Blair Bigham:
Absolutely. Interesting things happened at the very beginning of the pandemic in the ER, and this study really looks at one of the ways that we tried to address that. So the two things that we were seeing, first of all, a lot of people stopped coming to the emergency department. Now the cynic in me would be like, "Oh, that's because they didn't need to come. Finally, people are finding other ways of getting healthcare." But we know that people did need to come to the emergency department, but they were afraid to or they thought they were inconveniencing us or they wanted to stay away from people with COVID. And so there was certainly a need for virtually addressing people who were trying to avoid the ER, but who still needed some sort of urgent healthcare.
Dr. Mojola Omole:
Sure. And I think that the opportunity that the pandemic had presented was to expand virtual care and the iterations that we have of it today. Hopefully, when we speak to one of the co-authors of the study, we'll see how it's evolved.
Dr. Blair Bigham:
And we're also going to talk to a nurse practitioner who's working in virtual urgent care to hear that frontline perspective,
Dr. Mojola Omole:
The study captured a moment in time in the early days of the pandemic. Back in 2020, many patients were not accessing inpatient urgent care. In response, the province established 14 virtual urgent care initiatives across the province. One of them was at Toronto’s Sunnybrook Hospital. Dr. Justin Hall led the launch of the service. He's an emergency physician and the director for the Toronto Health Region's Virtual Urgent Care Program. He also is a co-author of the study in the CMAJ. Thanks so much for joining us today, Justin.
Dr. Justin Hall:
Thanks for having me.
Dr. Mojola Omole:
So this study really looked at virtual urgent care back in the early days of the pandemic. How much has virtual urgent care changed since then?
Dr. Justin Hall:
So it's a really good question, and it has changed a lot since that time. We're very fortunate that we've adopted a quality improvement approach, and we've iterated a number of times to improve the service. This has included adding in the capability for imaging, same and next day, the additional capabilities of adding in laboratory testing and ECG testing, things that we didn't have when we first started this service.
Dr. Mojola Omole:
What would you say, all the changes that you've made, what is probably the biggest change to the program that has either benefited patients or maybe less benefit?
Dr. Justin Hall:
I think one of the other big changes that we've done is actually the technology that we use. We always started using Zoom for this in the beginning, and we always had audio or telephone as a backup option for patients. But one of the things we heard early on was that our technology was a little bit clunky. It wasn't particularly user-friendly. And so we've redeveloped and redesigned a website for this, both for our own hospital and for the region, and it's a much more seamless user experience now. Patients are able to enter their basic demographic information for registration purposes. They're able to tell us a little bit of information about why they're seeking our service and what they're looking for help specifically. And we've added in dropdown options to help facilitate this to reduce the amount of typing, for example, that's required and the amount of time required to complete this.
We've also added in the ability so that patients can select a time that is most appropriate for them or most convenient with their own schedule. So they see an option of all of the different appointment slots upfront and to see if that would align with their own schedule if they'd have to change something that way. The other thing that it now also allows is it automate email and text message confirmation to the patient. This allows them to change any of the information with the quick click of a link from their phone or from their computer. And we found that this has been a much more seamless experience for patients.
Dr. Blair Bigham:
Justin, before these changes in the early days, tell us about the rush to implement this as the pandemic was unfolding. How did this come to be?
Dr. Justin Hall:
So this really stemmed out of an observation that our emergency departments were not seeing as many patients as they usually had, and in some cases across the province between 25% and 50% fewer visits. And as a frontline clinician, that was concerning not just to myself but others in that we thought there were lots of patients who probably would normally seek care but might've been avoiding care because of fear due to the pandemic or anxiety or just not sure whether they should actually attend an emergency department to seek care. And so based on this, we had a sort of a session locally to try to think about what would be an alternative way that we might be able to connect with our patients.
One of the other things that may be important to highlight is we looked at the patients that we typically serve in our department. We looked at postal code matching, and we found that many of the patients who were not coming in were those patients who might have been more vulnerable. When I say more vulnerable, they might have been in community housing. They may not have had access, for example, to some of the technology or may not have had transportation the same way that others would. And so because of this, we actually worked closely with some of our community organizations and partners to see what might be possible that way and whether they had noticed the same for their own clients within these buildings.
Dr. Mojola Omole:
Just going back to the study, how surprised were you that virtual urgent care didn't affect hospital visits to the emergency department?
Dr. Justin Hall:
It's interesting in that there's maybe two components to this. In this study, we do show that about 80% of patients did not require an immediate transfer to an emergency department. But what we also saw within this study is that it didn't necessarily prevent follow-up visits in the emergency department. And so I'm not completely surprised by this because this was early in the pandemic. This was set up very quickly, and the focus was on setting up a service as opposed to having it perfect. And I think that with the benefit of time and now that we've been able to have additional investigations, that's where really the benefit has come from. And I think if we ran the same study today with our current system, we would see slightly different results, would be my prediction.
Dr. Blair Bigham:
Do you have a sense of actual diversion? I guess there's two parts to this. How many people didn't end up flooding an emergency department during COVID because of the VUC, and how many people touch base with the VUC who otherwise might have gone without any healthcare at all?
Dr. Justin Hall:
And I think this is the tricky question. We asked every patient whether they would have attended the emergency department and with the benefit of hindsight, patients might have said, "Of course, I would've attended the emergency department." Or, "Of course, I wouldn't have attended the emergency department for this if I had access to my family doctor." When we asked that question to patients, 70% of them said they would have attended the emergency department without this service. However, we can't show the causal relationship that way. I don't know that they actually would have attended. That's just their stated behavior or intention.
Dr. Mojola Omole:
So when the virtual care was first established, it was in helping the fact that we were limiting in-person care. Now that most of the restrictions, well, all the restrictions have been lifted, what is the rationale now to have the VUCs?
Dr. Justin Hall:
I think we've really shifted in terms of what the purpose is now, and I think you've hit the nail on the head here. So when we've shifted from a pandemic response, recognizing that patients were not seeking care and might have benefited from having care to now, we are seeing this as a bit of a bridge. And what I mean by that is more and more patients coming out of the pandemic do not have access to a family physician, a nurse practitioner, or some type of longitudinal provider. And as a result of that, I think this service is now serving as a bridge for those patients who do not have a regular provider and who might use either a walk-in clinic or the emergency department actually as their default place to seek healthcare.
I think this is an interesting time as this continues to go forward because as has been widely shared in the media, the number of family physicians who either plan to retire over the next several years and the gap that will be within our system is quite concerning to me. I want to be clear that this isn't a replacement for a family physician or a longitudinal provider. We serve to address acute issues that are non-life threatening, but we are not trying to replace a family physician. That's not the intention of this, but for those who don't have one.
Dr. Blair Bigham:
Can an emerge doc who's discharging a patient in person refer for follow-up at the VUC or is a VUC really for first time visitors and then following up on their needs?
Dr. Justin Hall:
So it's really for both. So it is for those patients who might want a first time presentation or first time visit, but we also do refer patients from our in-person EDs as a means of helping with diversion. For example, a patient who might've come in needed an ultrasound to rule out a DVT, but we couldn't get it based on the time of day where the patient presented and then they receive their test the next day and they join us virtually to get their results.
Dr. Blair Bigham:
Oh, that's brilliant. Right now where I work, you come back the next day for your ultrasound and then you register and wait eight hours just to get the results.
Dr. Mojola Omole:
The other question that I had was if you refer someone to the ED, is there a way that they don't necessarily have to wait 20 hours to be seen?
Dr. Justin Hall:
So what we've tried to do or tried to help do-
Dr. Mojola Omole:
Because I just feel like they've seen either an emergency doctor already and you're just like, "Okay, you know what? This probably sounds like an appy. You need to go into the hospital, have an ultrasound." Instead of waiting to see another doctor, why can't they be fast tracked? Because that would still fast track the emergency visit, right?
Dr. Justin Hall:
So we have two streams, and so this is a really important point. We try to have a warm handoff. So for patients who would present to our hospital who already used our virtual service, we do have a means so that we can order their blood work, any imaging and any orders so that they would be available at the time of triage. So the patient would still be registered when the patient arrives in person, but we have this upfront so that their investigations can be started right away to try and save some of that time that you're mentioning.
For patients who do not come to our hospital site, all of our documentation and recommendations are shared on ConnectingOntario, the health report manager for the province. So it's not quite as smooth of a handoff, but we've looked at various ways of connecting with other emergency departments to do this. It's a little bit more challenging now that we're a regional service as opposed to a local service, but for patients presenting in person to our site, we do help to facilitate that care.
Dr. Mojola Omole:
I just think that even regionally would be great, right? Because it is still freeing up space in the emerg when someone's already seeing you and this is your recommendation, and I feel like that could be a great evolution of the program, almost like a virtual emergency department itself. Anyways, just thoughts.
Dr. Blair Bigham:
Justin, emerg docs loathe telephone services generally, the Telehealth experience in Ontario. Every emerg doc would say, "Well, Telehealth tells everybody to come to the emergency department." How has your virtual urgent care center avoided that trap of unnecessarily having people make their way into the hospital and spend their entire day waiting to see an in-person clinician?
Dr. Justin Hall:
I think there's two things that we do. One is a local solution whereby we have worked across different departments in the hospital to be able to get access to imaging and lab work and with our consultants so that we can make referrals even if they need to see, for example, an ophthalmologist I think they need to see today. I have a phone call with them and I can send them directly in our hospital as opposed to going through our emergency department. So we've designed a number of things in our hospital to be more seamless that way, to really try as much as possible to prevent an emergency department visit whenever it's safe and possible.
Dr. Mojola Omole:
It seems as if the program works well for you guys at Sunnybrook. I'm just being honest in the sense of it works well for the Sunnybrook patients who are in the Sunnybrook catchment, and so would there be a role for this being attached to different emergency departments as part of it, almost like the virtual component of the emerg?
Dr. Justin Hall:
So I think there are lots of possibilities that way. As highlighted by the study, initially there were 14 pilot sites. Each was housed at a given emergency department, Ontario Health and the team around them have shifted to a regional model. There are pros and cons of that. The challenge as you've just highlighted is that we don't have ordering abilities or privileges at multiple hospitals to be able to get it closest to the patient's home in many cases.
Dr. Mojola Omole:
So it would make more sense for this to be in each hospital then. Like why regionalize it? Why does Ontario Health want it regionalized?
Dr. Justin Hall:
Part of it is financial considerations and then how much volume someone would see or which department would see how much volume. And so some we're seeing very little and some we're seeing a lot. We happen to be one of the sites that were seeing quite a bit, and so I think they've tried to focus their efforts from a financial standpoint and an efficiency standpoint.
Dr. Blair Bigham:
So let's say for the entire city of Toronto you just wanted to have one clinician on duty for virtual. Ideally, they would be privileged in all 21 city hospitals so that they could order whatever you need, wherever your closest to.
Dr. Justin Hall:
I think in an ideal system, yeah, you would be able to order things at whatever hospital or even outpatient clinic or site for imaging when I think about that. If there's timely access, it wouldn't have to be at a hospital necessarily depending on the patient's condition. So trying to find a way to make care closest to home I think would be ideal here.
Dr. Mojola Omole:
So the program now seems to be evolving, you moved to nurse practitioners instead of physicians. I guess my question is, why and how does that work?
Dr. Justin Hall:
One of the things that came out of the early evaluation from this program was that many of the conditions that patients were presenting with were lower acuity, and it was one of the questions that was raised was whether other types of providers would be appropriate, physician assistants, nurse practitioners, other support team members. And so one of the things that Ontario Health has done is said in this current iteration or funding cycle that they wanted to test out whether that would play out and how nurse practitioners would be able to run this service compared to emergency physicians. Would there be any cost benefits there, any other efficiencies that might be gained there? Would it still be as safe and high quality as it was before?
Dr. Mojola Omole:
I guess my question is, why can't there be a mix? The same as in the emergency department, there is, at least at Scarborough, we have PAs who are working alongside emergency docs, other hospitals have nurse practitioners. Why can't we do the same mix of both?
Dr. Justin Hall:
I agree with you. and I do think probably the ideal model is a mix of different types of providers. One of the things we are testing right now at Sunnybrook is we have nurse practitioners are the frontline with our patients, but we actually have an emergency physician on call specifically for our virtual program so that if the nurse practitioner maybe has questions on whether the patient does need an urgent transfer to the emergency department or they have questions on the timeliness or they just want additional support, they have access to that. This is different than other regions. And so this is a new attempt at seeing what is the best model. I don't think we've landed on the best model, and I think it probably is a blended model of different types of providers to maximize the number of patients that can be seen while also ensuring that we are having that diversion ability as well.
Dr. Mojola Omole:
Let's say that you were Doug Ford, and you got to make any decision that you want like a Greenbelt Project, but instead for virtual urgent care, how would you want this program to evolve and what would you want it to look like in five years?
Dr. Justin Hall:
There are a few things that I think would really be beneficial here. The first that comes to mind is unified technology across the province. What I mean by that is so that we can have a seamless patient experience no matter where a patient is coming from. Right now, even with the regional models, there's a variety of technologies that patients would interact with and interact with across borders. And I think if there was one provincial system with a single webpage that had the various geographies or breakdowns of where a patient should attend, where they can sign up immediately in a patient friendly manner with the same information shared, that would be the first thing that comes to mind.
The second thing I would say is it gets back to one of the questions you asked on the benefit of maybe a hospital-based model versus a regional model. I think probably in the future there's going to be somewhere in between. Toronto region has a huge population, and I don't know if it's feasible to have privileges at all hospitals or all community outpatient clinics. And so I think it's important that maybe the future state has a few centers within each region. The same thing when I think about the north. The north region has a huge geography, but the population is more sparse, but maybe there do need to be multiple hubs there, more of a hub and spoke model that's used in other systems.
And then the third thing is probably around the care providers. And I think in the future this is going to involve emergency physicians, it's going to involve a physician assistants or nurse practitioners, maybe both, and it's going to probably involve other care team members, maybe a social worker, maybe someone who can navigate the Ontario health teams or to navigate the care experiences within a given region or around the patient's locale so that we can really get them so that they're not traveling unnecessarily. And so that really is the benefit of both convenience and safety here.
Dr. Mojola Omole:
Great. Thank you.
Dr. Justin Hall is an emergency physician and the director of the Toronto Health Region's Virtual Urgent Care Program.
Dr. Blair Bigham:
Let's step into the virtual urgent care service. Mary Dimeo is a nurse practitioner with 30 years of emergency experience. She recently made the move to Toronto Region's Virtual Urgent Care. Mary, thanks for joining us.
Mary Dimeo:
Thank you for having me.
Dr. Blair Bigham:
You have a lot of experience in the emergency department, and what type of challenges are there working in a virtual environment?
Mary Dimeo:
It's fast-paced. We typically will allot 20 minutes to a call. 10 minutes of that is talking to the patient, and then 10 minutes is scrambling. Oftentimes, we'll be obviously making notes, but we'll also be writing prescriptions. Sometimes we're connecting to the emergency physician for advice, or if we want to send a patient to the emergency, we always talk to them.
Dr. Blair Bigham:
And walk us through the rest of your day. What else goes on when you're on service?
Mary Dimeo:
We work from 1:00 PM to 9:00 PM. We start, we slowly get fed our patients. What we can do is we can check what the chief complaint is, which sometimes isn't what happens on the call, but so we'll see what the call's about then we just jump right in, have a discussion. It's supposed to be 10 minutes. Oftentimes, it might go over, particularly if it's a sensitive topic like mental health or if it's an older person who's just having some challenges. So I will take as long as it takes and then I can catch up later.
Dr. Blair Bigham:
And give us a sense of the type of ailments that you're seeing.
Mary Dimeo:
There's a lot of colds, viral illness, some COVID, some not. There's a lot of that. There's a lot of urinary tract infections, and then there's everything else in between. There's people with abdominal pain, people who have a chronic illness. Those are the most challenging calls actually, because it's very difficult to deal with someone's chronic health issue, and there's been other providers, even specialists involved, but we're trying to go back to square one and trying to figure out what we can do that would be helpful in this moment.
Dr. Blair Bigham:
How often are you seeing things that are sort of complicated like that where you either need to reach out to an emergency physician or refer the patient for testing or to an actual emergency department?
Mary Dimeo:
I would say probably about 50/50. So 50% of the calls are just dealt with by talking to them, giving them advice, telling them to go to the emergency or see their family doctor. About 50% do require prescriptions. I would say I do 18 calls a day, probably one patient at least has to go to the emergency.
Dr. Blair Bigham:
How easy is it for you to sort of do part of that emergency workup virtually like getting blood work or imaging so that you can kind of manage that without them having to go to a physical hospital?
Mary Dimeo:
Well, unfortunately, our imaging can only be done at Sunnybrook. That cannot be done in the community. Our labs can be done in the community. It's just filling out the forms and emailing them back and forth with the admin person can be a bit of a challenge because of computers.
Dr. Blair Bigham:
Sure. Do you feel comfortable with those cases where you know that your blood work might not come back quite as quick as if you were working in the ER, maybe you can follow up with them tomorrow. Are there a lot of cases like that where you're able to avoid an ER visit by sort of doing it all remotely?
Mary Dimeo:
I think actually we're very quick at getting people in for blood work and imaging. We can do that within 24 hours. That worst case scenario of 48 really depends on the patient and if they can get to the hospital, if I'm feeling comfortable about them getting their testing done, then I would think about sending them to the emergency.
Dr. Blair Bigham:
One of the reasons for virtual care is to sort of offload those physical visits. Do you have a sense of how many patients who use the virtual service would've gone to an ER had it not existed?
Mary Dimeo:
I think quite a few, to be honest. I mean, of course my threshold for going to emergency is very different than the general public. But sometimes a urinary tract infection, they often can't get into their family doctor because timely access is a huge issue and so that needs to be dealt with now. You don't want them getting an infection in their kidney, so we have to get antibiotics to them. So those patients are easily diverted. There's a lot of people without family doctors. And even if you have a family doctor, I don't know about you personally, but for me, I have to wait a week or two to see my family doctor.
So those types of people would typically go through the emergency because we're seen as the only alternative, especially if it's after hours from walk-in clinic times or physician's after hours clinics. So I do think that we do divert quite a few. There's people who are elderly, who have chronic pain, who can't sit in the emergency to wait. So even though it's something simple, we can divert them from the emergency by caring for them from their home.
Dr. Blair Bigham:
Gotcha.
Dr. Mojola Omole:
You mentioned before that there's sometimes you have people who this is more of a chronic, maybe an acute on chronic issue. Let's say there's a person with a chronic issue, are you able to follow up with them again in a week or that type of thing to kind of have a longitudinal care with them, or is it more really just dealing with whatever is acute?
Mary Dimeo:
That's a good question. I think what I do is identify if there's an emergent or urgent issue involved and then I will get involved, but I don't really... I mean, we will have patients that I tell to come back, but I don't want to be following them per se because I don't think that's what we're about. I think we're like an emergency. We're episodic care. So I don't want to be dealing with someone's blood pressure, because I don't want to be changing their medications, especially when they have a primary care provider who can do that.
So the chronic ones are challenging. I personally look for, is there something that's distressing or worrisome about this? And then I will manage that for sure. Sometimes I'll even send them to the emergency, but otherwise I just try to deal with what's there in front of me. And I often will tell patients, "Your family doctor really is the person who can deal with this and they are your quarterback and they're the ones who can get the specialist that's closer to you than Sunnybrook." So I do try to encourage them to follow with their primary care provider.
Dr. Mojola Omole:
And I'm sure their primary care provider gets a copy of the notes and of the conversation, right?
Mary Dimeo:
Yes. So we document it and then it's cc'd immediately to the primary care provider.
Dr. Blair Bigham:
What gaps would happen if the VUC service vanished overnight?
Mary Dimeo:
I think a lot. I mean, it is part of the healthcare access for people. It's convenient, it's timely, which is such a big issue in healthcare these days. So I think there would be a lot of people falling through the cracks, potentially acute illnesses would become more serious, chronic illnesses would be be worsened. People would just ignore their health, which they do anyway, but it would worsen that, right? So I think it's an important part of the whole healthcare system.
Dr. Blair Bigham:
Awesome. Mary Dimeo is a nurse practitioner working in the Toronto region's virtual urgent care service.
Dr. Mojola Omole:
So Blair, what are your initial reactions after talking to Mary and Justin?
Dr. Blair Bigham:
Well, there's no doubt that virtual care plays and should play a bigger role in the healthcare system, particularly if for no other reason than it's just easy. Generally, it's easy and convenient for people. And I think that's what we heard from Mary. We heard from Justin that convenience is a big part of this, which is nice because usually with a healthcare intervention, we're trying to convince people to change their behavior in a way that maybe they don't want to, but here we have an intervention that actually makes their lives easier. People want this service, and I think that doctors and nurses and hospitals and governments also want this service because it should be cheaper to offer this service. Being able to have people worked up within 24 hours instead of eight hours is usually fine. In the emergency department, we do see a lot of things that are subacute that could be worked up over 24 hours, 48 hours, but there's just no way to do that.
The next clinic appointment is three weeks away, their family doctor's away on vacation or can't see them for two weeks and nobody wants to let chest pain that doesn't sound ischemic go for two weeks, but for 24 hours when I have a low pretest probability of anything concerning, yeah, let's go ahead and just go to your neighborhood blood lab, get your blood work done, it'll ping on a nurse practitioner's phone. We'll review it, we'll give you a call tomorrow. It just makes sense.
But even with what Justin's created, it seems like there's still a lot of wrinkles to smooth out. People have to go to Sunnybrook for their imaging, yet they get phone calls from people as far away as Kingston or north of Barrie. There's certainly a lot of ways that we can make this better and scale it and make it so that people can access it. And if you can't access it through internet or through video, I do think that over the phone is probably good enough most of the time. And if not, maybe there's even ways to partner with EMS services, with paramedics, with other people who exist in the field who can help fill the gap but not necessarily bring you to an emergency department. It just seems like such a slam dunk for improving the system in so many ways. That is win-win-win.
Dr. Mojola Omole:
For sure. What I was listening to was that for me, there are certain things that I've taken umbrage with in terms of Ontario Health's decisions. One of them being the fact that regionalize it, which I understand that regionalize it saves money in certain ways, but I think often times we're so concerned about saving money, we don't realize that you save money upstream, but you end up wasting it downstream. I do think this works better if it's actually attached to emergency departments.
I think our big centers, I mean this pilot study, this is in Ontario, but this could apply to any province. So we're in Toronto, we have multiple regions, but being able to have doctors and nurse practitioners who work in ER actually staff this as if it's another shift they're staffing, I do think actually makes more sense because you have a relationship with the hospital that you work at, and so you can say, "Okay, I need this lab done. I need this imaging done." And then they could be followed up. If you have to send somebody in, then they're bypassing part of triage because they've already been triaged over the phone.
Dr. Blair Bigham:
I can see a lot of benefits to that type of thing because then I would know probably the liver specialist or the cardiologist who you're already being seen by, and I would know my local wait times and I would know my local shelters and my local resources. And so yeah, should this be a single physician and nurse practitioner sitting in Toronto dealing with calls from all across the province? Well, that may sound appealing from sort of a system design perspective. At the end of the day, emergency medicine, urgent care, you got to understand the community that the people are living in in order to help guide some of the resources that they need. And it seems like we might lose a bit of that with regionalization.
Dr. Mojola Omole:
And also the relationships, right?
Dr. Blair Bigham:
Totally.
Dr. Mojola Omole:
Medicine is about relationships. If you are in North Bay, you know the family doctor, so you can send a message, "Hey, you know what? I saw this patient virtually. I think they're okay now, but they probably need to follow up sooner rather than later." A family doctor appreciates when they actually get phone call from specialists.
Dr. Blair Bigham:
Especially when you have that relationship.
Dr. Mojola Omole:
The other thing I take umbrage with is the fact of them moving it solely to nurse practitioners. Yes, it seems that it might save money in certain aspects because physicians, emergency physicians are paid higher by Ontario Health than nurse practitioners, but there are certain limits to what nurse practitioners can do, and nurse practitioners are the first ones to tell you that, "You know what? This is how far up I can go, and then I do need the help of the emergency physician." I also think on top of it is that for this to work, you need people like Mary who are seasoned. She's like one of the OG kind of nurses where they look at you and you don't even ask them a question, you just run into the room because you know that something needs to be done.
So I think being able to staff this with both emergency physicians and nurse practitioners is important, and that this cannot just be NPs because we do know that nurse practitioners and doctors have different referrals and also ordering styles. And even though it seems that the pay per hour is going to be less with a nurse practitioner, you're going to pay for it in terms of tests. And healthcare is supposed to be collaborative. We're not supposed to just be one person who's doing work. And so I personally, if anybody from Ontario Health is listening, think that it should be both nurse practitioners and emergency physicians.
Dr. Blair Bigham:
And it's good to hear that Justin is kind of looking into the outcomes of, depending on who's on the phone, what are your outcomes and how do things differ? And certainly we also sort of oversimplify things. Like a nurse practitioner like Mary is very different from a nurse practitioner who might not have many years of experience or who might have experience, but not in an emergency setting. And so I think you're absolutely right. Wondering what is the best model to deliver virtual care is probably hot on the minds of everybody.
Dr. Mojola Omole:
Okay. Blair, this has been a very-
Dr. Blair Bigham:
This has been so lovely, Jola.
Dr. Mojola Omole:
Yeah, it's a really thought-provoking topic and it really is energizing because any process that's helping us reimagine how we deliver care to our communities is really invigorating.
Dr. Blair Bigham:
Absolutely. That's it for this week on the CMAJ podcast. What a great discussion. Please help us spread the word and get the conversation to keep on going online, offline. Share us with your colleagues, share us with your friends. One of the things that helps the most is if you can rate and review us. Please leave a text review on wherever it is you download your audio. It goes a long way to helping us climb to the top. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.