Can Answers to the Health Workforce Crisis Be Found in Equity-Informed Digital Health?

In this paper, we describe current pressures on health human resources (HHRs) in the Canadian context and related factors that impact equity-deserving communities/populations. We explore issues of HHR challenges in rural, remote and urban underserved contexts and explore the associated benefits and challenges of incorporating digital health (DH). We present examples and evidence of integrating hybrid models of care as a means of supporting HHRs via DH in the publicly funded health system.

Defining "Essential Digital Health for the Underserved".

The World Health Organization envisions achieving "Health for All," to strive for equitable access to important health information and services to attain wellness (WHO 2023a). The COVID-19 pandemic reshaped the Canadian health system toward increasing digital health services, which improved access for some but underserved others. Integrating digital health into holistic health services delivery deserves careful consideration. This paper introduces the concept of "essential digital health for the underserved," by first defining the terms "digital health," "essential" and "underserved." Then, we share a summary of a discussion at a May 2023 conference with stakeholders, including patients, caregivers, health professionals, health policy makers, private sectors and health researchers. A series of papers follow to explore how digital health can help chart a responsible course for the future of essential digital health in Canada. In this post-pandemic era - with a health human resources shortage through attrition and retirement, an increased health service demand from patients and a greater strain on our recovering economy - innovative solutions need to be implemented to strengthen our Canadian health system.

Learning Health Systems: A Paradigm Shift in What We Can Do about Digital Health Inequities.

Learning health systems (LHSs) embed social accountability into everyday workflows and can inform how governments build bridges across the digital health divide. They shape partnerships using rapid cycles of data-driven learning to respond to patients' calls to action for equity from digital health. Adopting the LHS approach involves re-distributing power, which is likely to be met with resistance. We use the LHS example of British Columbia's 811 services to highlight how infrastructure was created to provide care and answer questions about access to digital health, outcomes from it and the financial impact passed on to patients. In the concluding section, we offer an accountability framework that facilitates partnerships in making digital health more equitable.

Real-Time Virtual Support as an Emergency Department Strategy for Rural, Remote, and Indigenous Communities in British Columbia: Descriptive Case Study.

BACKGROUND: British Columbia has over 200 rural, remote, and Indigenous communities that have limited health care resources due to physician isolation, sparsity in clinical resources, the lack of collegial support, and provider burnout. Real-time virtual support (RTVS) peer-to-peer pathways provide support to patients and providers. Amid the COVID-19 pandemic exacerbating existing health care disparities and equitable access to timely care, RTVS presents a portable and additional opportunity to be deployed in a hospital or patient home setting in rural communities. We highlight the story of the Rural Urgent Doctor in-aid (RUDi) pathway within RTVS that successfully supported the Dawson Creek District Hospital (DCDH) emergency department (ED) in 2021. OBJECTIVE: This study aims to describe the rapid implementation process and identify facilitators and barriers to successful implementation. METHODS: This case study is grounded in the Quadruple Aim and Social Accountability frameworks for health systems learning. The entire study period was approximately 6 months. After 1 week of implementation, we interviewed RUDi physicians, DCDH staff, health authority leadership, and RTVS staff to gather their experiences. Content analysis was used to identify themes that emerged from the interviews. RESULTS: RUDi physicians covered 39 overnight shifts and were the most responsible providers (MRPs) for 245 patients who presented to the DCDH ED. A total of 17 interviews with key informants revealed important themes related to leadership and relationships as facilitators of the coverage's success, the experience of remote physician support, providing a "safety net," finding new ways of interprofessional collaboration, and the need for extensive IT support throughout. Quality improvement findings identified barriers and demonstrated tangible recommendations for how this model of support can be improved in future cases. CONCLUSIONS: By acting as the MRP during overnight ED shifts, RUDi prevented the closure of the DCDH ED and the diversion of patients to another rural hospital. Rapid codevelopment and implementation of digital health solutions can be leveraged with existing partnerships and mutual trust between RTVS and rural EDs to ease the pressures of a physician shortage, particularly during COVID-19. By establishing new and modified clinical workflows, RTVS provides a safety net for rural patients and providers challenged by burnout. This case study provides learnings to be implemented to serve future rural, remote, and Indigenous communities in crisis.

Real-time virtual supports improving health equity and access in British Columbia.

In British Columbia (BC) and across the territories of over 200 First Nations and 39 Métis Nation Chartered communities, the COVID-19 pandemic catalyzed a group of partner organizations to rapidly establish seven virtual care pathways under the Real-Time Virtual Support (RTVS) network. They aimed to address inequitable access and multiple barriers to healthcare faced by rural, remote, and Indigenous communities, and provide pan-provincial services. Mixed-method evaluation assessed implementation, patient and provider experience, quality improvement, cultural safety, and sustainability. Pathways supported 38,905 patient encounters and offered 29,544 hours of peer-to-peer support from April 2020 to March 2021. Mean monthly encounter growth was 178.0% (standard deviation = 252.1%). Ninety percent of patients were satisfied with the care experience; 94% of providers enjoyed delivering virtual care. Consistent growth suggests that the virtual pathways met the needs of providers and patients in rural, remote, and Indigenous communities, and supported virtual access to care in BC.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Telehealth as a Means of Enabling Health Equity.

OBJECTIVE: The goal of this paper is to provide a consensus review on telehealth delivery prior to and during the COVID-19 pandemic to develop a set of recommendations for designing telehealth services and tools that contribute to system resilience and equitable health. METHODS: The IMIA-Telehealth Working Group (WG) members conducted a two-step approach to understand the role of telehealth in enabling global health equity. We first conducted a consensus review on the topic followed by a modified Delphi process to respond to four questions related to the role telehealth can play in developing a resilient and equitable health system. RESULTS: Fifteen WG members from eight countries participated in the Delphi process to share their views. The experts agreed that while telehealth services before and during COVID-19 pandemic have enhanced the delivery of and access to healthcare services, they were also concerned that global telehealth delivery has not been equal for everyone. The group came to a consensus that health system concepts including technology, financing, access to medical supplies and equipment, and governance capacity can all impact the delivery of telehealth services. CONCLUSION: Telehealth played a significant role in delivering healthcare services during the pandemic. However, telehealth delivery has also led to unintended consequences (UICs) including inequity issues and an increase in the digital divide. Telehealth practitioners, professionals and system designers therefore need to purposely design for equity as part of achieving broader health system goals.

Home Telemonitoring Technology for Patients With Heart Failure: Cost-Consequence Analysis of a Pilot Study.

BACKGROUND: Heart failure (HF) is a costly health condition and a major public health problem. It is estimated that 2%-3% of the population in developed countries has HF, and the prevalence increases to 8% among patients aged ≥75 years. Home telemonitoring is a form of noninvasive, remote patient monitoring that aims to improve the care and management of patients with chronic HF. Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring (TEC4Home) is a project that implements and evaluates a comprehensive home monitoring protocol designed to support patients with HF as they transition from the emergency department to home. OBJECTIVE: The aim of this study is to assess the cost of using the home monitoring platform (TEC4Home) relative to usual care for patients with HF. METHODS: This study is a cost-consequence analysis of the TEC4Home pilot study. The analysis was conducted from a partial societal perspective, including direct and indirect health care costs. The aim is to assess the costs of the home monitoring platform relative to usual care and track costs related to health care utilization during the 90-day postdischarge period. RESULTS: Economic analysis of the TEC4Home pilot study showed a positive trend in cost savings for patients using TEC4Home. From both the health system perspective (Pre TEC4Home cost per patient: CAD $2924 vs post TEC4Home cost per patient: CAD $1293; P=.01) and partial societal perspective (Pre TEC4Home cost per patient: CAD $2411 vs post TEC4Home cost per patient: CAD $1108; P=.01), we observed a statistically significant cost saving per patient. CONCLUSIONS: In line with the advantages of conducting an economic analysis alongside a feasibility study, the economic analysis of the TEC4Home pilot study facilitated the piloting of patient questionnaires and informed the methodology for a full clinical trial.

Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study.

BACKGROUND: Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life. OBJECTIVE: Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial. METHODS: Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient's condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods. RESULTS: Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management. CONCLUSIONS: Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia. TRIAL REGISTRATION: ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384.

Remote assessment via video evaluation (RAVVE): a pilot study to trial video-enabled peer feedback on clinical performance.

BACKGROUND: Video review processes for evaluation and coaching are often incorporated into medical education as a means to accurately capture physician-patient interactions. Compared to direct observation they offer the advantage of overcoming many logistical challenges. However, the suitability and viability of using video-based peer consultations for professional development requires further investigation. This study aims to explore the acceptability and feasibility of video-based peer feedback to support professional development and quality improvement in patient care. METHODS: Five rheumatologists each provided four videos of patient consultations. Peers evaluated the videos using five-point scales, providing annotations in the video recordings, and offering recommendations. The rheumatologists reviewed the videos of their own four patient interactions along with the feedback. They were asked to document if they would make practice changes based on the feedback. Focus groups were conducted and analysed to explore the effectiveness of video-based peer feedback in assisting physicians to improve clinical practice. RESULTS: Participants felt the video-based feedback provided accurate and detailed information in a more convenient, less intrusive manner than direct observation. Observations made through video review enabled participants to evaluate more detailed information than a chart review alone. Participants believed that reviewing recorded consultations allowed them to reflect on their practice and gain insight into alternative communication methods. CONCLUSIONS: Video-based peer feedback and self-review of clinical performance is an acceptable and pragmatic approach to support professional development and improve clinical care among peer clinicians. Further investigation into the effectiveness of this approach is needed.

The Use of eHealth Applications in Hong Kong: Results of a Random-Digit Dialing Survey.

eHealth has become popular worldwide, and it is transforming health care. However, studies examining  the use of eHealth applications in the Chinese population are scarce. The study reports on the characteristics of eHealth applications in Hong Kong information and communication technology (ICT) users, their attitudes towards eHealth, and their reasons for not using eHealth applications. A cross-sectional random-digit dialing survey targeting adults using ICT was conducted in Hong Kong to elicit information on respondents' use of and attitudes towards eHealth. A total of 495 ICT users completed the survey, of whom 353 (71.3%) were eHealth users. A smartphone was the most frequent way of performing eHealth activities (71.7%). The most prevalent eHealth activity was reading about health/illness (86.4%), with 93.5% indicating that eHealth applications improved their understanding of health care issues. People with less education were less likely to use eHealth applications. Non-eHealth users indicated that the main reasons for not using eHealth applications were lack of interest in health information (49.3%) and lack of confidence in the reliability of online information (45.1%). Quality monitoring of health information available on ICTs and tailoring the design and readability are recommended to meet the needs of those seeking health resources and to promote eHealth. Evidence from the study demonstrates the potential of eHealth to improve the dissemination of health information in Hong Kong, and it provides a basis for improving eHealth integration.

Knowledge to action framework for home health monitoring.

Chronic disease management is a grand challenge, both to the patients for optimal management and to the overall health system with cost utilization. Emerging research evidence suggests that Home Health Monitoring (HHM) using home-based, remoting monitoring technologies can improve the patients' quality of life, self-management, and achieve cost-effectiveness for the health system. How should HHM be introduced and integrated appropriately into the current healthcare delivery pathways to improve patient care and collect evidence of benefits simultaneously? The Knowledge to Action (KTA) framework is an effective approach in the implementation science literature to methodically guide the translation of evidence-based research findings into practice, putting knowledge into practical use. This article examines the use of the seven-step KTA model to address implementation facilitators and barriers of applying HHM in chronic disease management and then focus on its applicability on chronic obstructive pulmonary disease as an example.

Applying the Resilient Health System Framework for Universal Health Coverage.

Since the 1978 Declaration of Alma-Ata affirming health as a fundamental human right, policy-makers and stakeholders have proposed many different strategies to achieve the goal of 'health for all'. However, globally there still remains a lack of access to health information and quality health care, especially in low- and middle-income countries (LMIC). Digital health holds great promise to improve access and quality of care. We propose using the "resilient health system framework" as a guide to scale-up digital health as a means to achieve universal health care (UHC) and health for all. This article serves as a call to action for all governments to include population-based digital health tools as a foundational element in on-going health system priorities and service delivery.

Medical students' self-reported preparedness and attitudes in providing care to ethnic minorities.

BACKGROUND: To assess medical students' self-reported preparedness to provide care to ethnic minorities, factors that influence preparedness, and attitudes toward cultural competency training. METHODS: A cross-sectional study, which invited University of British Columbia medical students to participate in a survey on student demographics, knowledge and awareness, preparedness and willingness, and personal attitudes. Of 1024, eligible, 301 students consented to study. RESULTS: Students across all year levels felt significantly less ready to provide care for non-English speaking Chinese patients compared to "any" patients. Proficiency in working with interpreters was correlated with readiness, OR 4.447 (1.606-12.315) along with 3rd and 4th year level in medical school, OR 3.550 (1.378-9.141) and 4.424 (1.577-12.415), respectively. Over 80% of respondents reported interest in learning more about the barriers and possible ways of overcoming them. CONCLUSIONS: More opportunities for cultural competency training in the medical curriculum are warranted and would be welcomed by the students.

Clinical telehealth across the disciplines: lessons learned.

Videoconferencing technologies can vastly expand the reach of healthcare practitioners by providing patients (particularly those in rural/remote areas) with unprecedented access to services. While this represents a fundamental shift in the way that healthcare professionals care for their patients, very little is known about the impact of these technologies on clinical workflow practices and interprofessional collaboration. In order to better understand this, we have conducted a focused literature review, with the aim of providing policymakers, administrators, and healthcare professionals with an evidence-based foundation for decision-making. A total of 397 articles focused on videoconferencing in clinical contexts were retrieved, with 225 used to produce this literature review. Literature in the fields of medicine (including general and family practitioners and specialists in neurology, dermatology, radiology, orthopedics, rheumatology, surgery, cardiology, pediatrics, pathology, renal care, genetics, and psychiatry), nursing (including hospital-based, community-based, nursing homes, and home-based care), pharmacy, the rehabilitation sciences (including occupational and physical therapy), social work, and speech pathology were included in the review. Full utilization of the capacity of videoconferencing tools in clinical contexts requires some basic necessary technical conditions to be in place (including basic technological infrastructure, site-to-site technological compatibility, and available technical support). The available literature also elucidates key strategies for organizational readiness and technology adoption (including the development of a change management and user training plan, understanding program cost and remuneration issues, development of organizational protocols for system use, and strategies to promote interprofessional collaboration).

Measuring prescribing improvements in pragmatic trials of educational tools for general practitioners.

Randomized pragmatic trials of drugs, physician education and drug policies are needed to improve pharmacosurveillance and cost-effectiveness of prescribing. Since 1994, we have developed and tested methods for low-cost education and policy trials to improve prescribing in primary care in Canada. We review methodology for using drug claims and other health services data to evaluate prescribing improvement programs and policies. We apply the lessons to a proposed trial of physician education tools (PET) for quality improvement of prescribing. Design issues for the trial include defining the potential programme in causal terms using counterfactuals, narrowing the denominator to the population affected, excluding noise from the numerator, calculating the prescribing preference, adjusting for baseline differences, controlling for modifiers and confounders, accounting for uncertainty when measuring impacts, and grouping practices for feedback and recognition. Data from a randomized trial of academic detailing illustrate measurement challenges. A decade of progress on methods for evaluating prescribing improvement programs with drug claims data has enabled planning of routine randomized pragmatic trials of education and policies in primary care in Canada.

An assessment of the telehealth needs and health-care priorities of Tanna Island: a remote, under-served and vulnerable population.

We surveyed eight Canadian physicians who had each provided medical care for six months on the remote and under-served island of Tanna in Vanuatu. The most frequently encountered medical problems on Tanna were infectious diseases (tuberculosis, hepatitis, abscesses, malaria, pneumonia, typhoid fever, meningitis and skin infections). When physicians were asked about the top three health-care priorities, they ranked tuberculosis control, clean water and improved health-care delivery/communication between hospital and outposts as most important. The key issues were: (1) basic public health needs and infrastructure development are higher in priority than telehealth; (2) telehealth consultants must have knowledge pertinent to local conditions and resources available to the population; (3) electronic equipment suited to tropical environments is needed; (4) projects must be developed locally rather than internationally. Understanding how telehealth can provide support to health professionals under challenging conditions may assist with the health priorities in developing countries and potentially provide access to resources both locally and internationally.

Technology-enabled knowledge translation: frameworks to promote research and practice.

Knowledge translation articulates how new scientific insights can be implemented efficiently into clinical practice to reap maximal health benefits. Modern information and communication technologies can be effective tools to help in the collection, processing, and targeted distribution of information from which clinicians, researchers, administrators, policy makers in health, and the public can benefit. Effective implementation of knowledge translation through the use of information and communication technologies, or technology-enabled knowledge translation (TEKT), would benefit both the individual health professional and the health system. Successful TEKT in health requires cultivation and acceptance in the following key domains: Perceiving types of knowledge and ways in which clinicians acquire and apply knowledge in practice. Understanding the conceptual and contextual frameworks of information and communication technologies applied to health systems, particularly the push, pull, and exchange communication models. Comprehending essential issues in implementation of information and communication technologies and strategies to take advantage of emerging opportunities and overcome existing barriers. Establishing a common and widely acceptable evaluation framework in order that researchers can compare various methodologies in their rightful contexts in TEKT research and adoption. Achieving harmony and common understanding in these areas will go a long way in fostering a fertile and innovative environment to encourage research and advance understanding in this exciting domain of TEKT.