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Timely, in-person access to health care is a challenge for people living with conditions such as stroke that result in frailty, loss of independence, restrictions in driving and mobility, and physical and cognitive decline. In Southeastern Ontario, access is further complicated by rurality and the long travel distances to visit physician clinics. There is a need to make health care more accessible and convenient. Home virtual visits (electronic visits, eVisits) can conveniently connect physicians to patients. Physicians use a secure personal videoconferencing tool to connect to patients in their homes. Patients use their device of choice (smartphone, tablet, laptop, or desktop) for the visit.
This study aimed to assess the feasibility and logistics of implementing eVisits in a stroke prevention clinic for seniors.
A 6-month eVisit pilot study was initiated in the Kingston Health Sciences Centre stroke prevention clinic in August 2018. eVisits were used only for follow-up patient encounters. An integrated evaluation was used to test the impact of the program on clinic workflow and patient satisfaction. Patient satisfaction was evaluated by telephone interviews, using a brief questionnaire. Access and patient satisfaction metrics were compared with concurrent standard of care (patients’ prior personal experience with in-person visits). Values are presented as median (interquartile range).
There were 75 subjects in the pilot. The patients were aged 65 (56-73.5) years, and 39% (29/75) resided in rural areas. There was a shorter wait for an appointment by eVisit versus in-person (mean 59.98 [SD 48.36] days vs mean 78.36 [SD 50.54] days;
The eVisit program was well received by patients, deemed to be safe by physicians, and avoided unnecessary patient travel and expense. It also has the potential to reduce health care costs. We plan to scale the project within the department and the institution.
Canadians face many barriers while accessing outpatient health care services, including accessibility, availability, acceptability, and personal choice [
Traditional practice utilizes in-person interaction to establish the patient-physician relationship and to complete a comprehensive clinical evaluation, including history and physical examination. However, follow-up care, including symptom management, diagnostics, and therapeutic decision making require less in-person interaction and may be achieved by virtual visits. Virtual visits, also known as eVisits, are a secure, 2-way digital communication between health providers and their patients. eVisits may include emails, short message service text messaging, and videoconferencing [
eVisits and other telemedicine modalities across Ontario, Canada, are facilitated by technologies provided by the Ontario Telemedicine Network (OTN), a not-for-profit organization funded by the Ontario Ministry of Health and Long-Term Care (MOHLTC). For the purposes of this publication, “eVisit” refers to personal, secure videoconferencing between the health care provider and the patient. Unlike conventional telehealth modalities, an eVisit does not need new infrastructure, such as dedicated videoconferencing equipment, peripheral devices, or a telemedicine facility, and the patient remains in their home. In an eVisit, the physician and patient interface using electronic equipment that is widely available, such as smartphones and tablets. The traditional telemedicine model with the patient at a remote site (satellite site) reduces the patient travel burden but is still costly to the health care system as significant infrastructure is used at both ends. eVisits have been shown to be feasible, acceptable, and yield similar clinical outcomes compared with in-person patient cohorts in an interdisciplinary obesity treatment program for adolescents in Ontario, Canada [
Whether eVisits would also be beneficial to seniors, a group traditionally viewed as being less technologically adept, was tested in a 6-month pilot project in a high-volume stroke prevention clinic in Ontario at the Kingston Health Sciences Centre (KHSC). The results of this pilot program indicated that the eVisit was well received by patients and has the potential to provide cost savings to both patients and the health care system.
The eVisit pilot study was initiated at KHSC in August 2018 for a 6-month period with the objective to assess the feasibility and logistics of implementing eVisits in an adult specialty disease clinic catering predominantly to seniors. An integrated evaluation was designed to test the impact of the pilot program both on clinic workflow and patient satisfaction using a telephone survey. The workflow of the eVisit intervention in the stroke prevention clinic is presented in
Electronic visit workflow. BP: blood pressure; OTN: Ontario Telemedicine Network.
No cognitive issues.
No loss of communication abilities.
No physical deficits and loss of functional abilities.
No sensory or perceptual deficits.
No visual field deficits with functional implications.
Patient/substitute decision maker (SDM) willing to do an electronic visit (eVisit) for follow-up care.
Patient/SDM has internet-enabled device (smartphone, tablet, or computer).
Patient/SDM has access to an internet connection.
Patient/SDM has a secure place to perform an eVisit.
The study subjects were selected from patients routinely seen in the stroke prevention clinic using prespecified criteria (
eVisits were used only for the follow-up visits. Patients had to fulfill the
The definition for
We also performed a preliminary economic analysis to estimate hypothetical out-of-pocket (OOP) patient cost savings of eVisits and opportunity costs of in-person outpatient care. Opportunity cost are defined as benefits foregone by the particular use of resources, resources which could be otherwise allocated for other health care priorities [
The OOP expenses were not captured using a specially designed survey; however, approximate reasonable OOP expenses were estimated using the cost of travel, parking, potential loss of pay, and total cost (
Our institution does not collect or report outpatient costing to Canadian Institute for Health Information (CIHI), so we used the available provincial outpatient costing data for reference [
Data were entered into Epidata software (The Epidata Association, Denmark) and were analyzed using STATA v15.0 (StataCorp LLC, USA). The data was analyzed using summary statistics and Wilcoxon Signed Rank Sum test for paired data. Values are stated as the mean and interquartile range (IQR). A
Ethics approval for the pilot study was obtained, permitting for chart review and data collection (Queen’s University Ethics ROMEO # 6025439).
There were a total of 75 eVisits from August 2018 to January 2019. The details on the overall clinic volumes and the number of eVisits are provided in the
The mean (SD) and median (IQR) age of the patients was 63.7(14.3) and 65 years (56-73.5), respectively. Of the study patients, 67% (50/75) were male, 51% (38/75) were under age 65, 32% (24/75) were aged 65-75, and 17% (13/75) were over age 75. Mobile internet devices, including tablets (68%; 51/75) and smartphones (24%; 18/75), were most widely used for the eVisits, likely because of ease of use and setup. Laptops were used for 7% (5/75) and desktops were used for 1% (1/75) of eVisits. The mean (SD) and median (IQR) time spent by the physician and the patient for an eVisit encounter was 9.81 (4.46) and 10 (9-12) min, respectively. The proportion of rural residents who performed eVisits was 39% (29/75). A single family member accompanied the patient in 60% (45/75) of the eVisit encounters. A total of 11% (8/75) of the patients were at their place of work for the eVisit, the eVisit was done in a secure location selected by the patient, and none of them needed to take time off work.
The Wilcoxon signed-rank test showed significant reduction (
The savings on travel avoided, time savings, and direct patient OOP expenses are presented in
The various components of patient care during the eVisit included, when relevant, a review of imaging tests (33%; 24/72), cardiac tests (43%; 31/72), lab tests (26%; 19/72), consults from other specialists (28%; 20/72), medication reconciliation (93%; 67/72), and potential new tests or interventions (50%; 36/72). Screen sharing was used for 28% (20/72) of eVisits. The diagnosis at the time of eVisit included stroke (49%; 35/72), transient ischemic attack (33%; 24/72), migraine (3%; 2/72), epilepsy (8%; 6/72), or other (7%; 5/72).
A telephone patient experience survey was also completed by patients that had an eVisit with a good survey response (46%; 33/72). The degree of patient satisfaction captured using the survey questionnaire was very high (
Patient experience from electronic visits (N=33).
Question | n (%) | |
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Yes | 33 (100) |
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Yes | 32 (97) |
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Yes | 33 (100) |
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Yes | 33 (100) |
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Yes | 33 (100) |
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Better | 12 (36) |
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Same | 19 (58) |
|
Not sure | 2 (6) |
|
Worse | 0 (0) |
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Definitely | 31 (94) |
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Probably | 2 (6) |
|
Neutral, probably not, definitely not, not sure | 0 (0) |
|
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0-7 | 2 (6) |
|
8-100 | 31 (94) |
aeVisit: electronic visit.
The estimates for OOP costs saved are presented in
The outpatient hospital-based health care costs in Ontario and Alberta for codes E751 and E752 based on CIHI CACS for 2016/17 are provided in the
“It is really important for a patient to have a proper conversation with their doctor, to ask questions, and to get answers which put my mind at rest. I felt as if I was in your office talking to you face to face. Not having to arrange transportation to get to your office was a real help. Now that I am not able to drive, mobility within the community is a real issue. I hope that this will be something you can offer to patients regularly.” [Female patient, aged 90 years]
“The e-visit saved time and a lot of stress that is involved in taking an elderly patient out especially in bad weather.” [Family of a male patient aged 88 years]
“It was nice not to have had to drive to the hospital, pay for parking, and make the physical effort of getting to the appointment destination.” [Male patient, aged 88 years]
Estimated out-of-pocket cost savings to patients in Canada.
Out-of-pocket expenses category | Total (Can $) | Can $, mean (SD) | Can $, median (interquartile range) |
Patient self-reported cost for in-person visit (n=24) | 417 | 13.4 (14.5) | 10 (5-15) |
Estimated travel cost for patients | 2384.46 | 33.13 (36.92) | 16.55 (6.16-45.21) |
Estimated total out-of-pocket savings | 5393.97 | 74.92 (57.99) | 52.83 (31.26-94.53) |
We demonstrated that eVisits could be successfully implemented for secondary prevention of stroke in an adult neurology clinic catering predominantly to seniors. eVisits are time-efficient for physicians and patients, taking a median time of 10 min while avoiding the logistical challenges of an in-person encounter and reducing OOP expenses. Patient satisfaction is very high with the eVisits. A significant proportion (33%;11/33) of our cohort reported the experience to be better than an in-person encounter. During the eVisit, it is possible to perform most of the conventional components of clinical care that happen during a routine follow-up clinic visit for this patient population. The proportion of cancellations and no-shows is minimal, highlighting the impact of the eVisits on the overall efficiency of this model of ambulatory care. There is a significant reduction in the wait times for the patients via eVisit compared with in-person follow-up, which is likely because of the lack of the need for traditional health care infrastructure. The direct translatable savings to the patients with regard to OOP expenses for travel avoided and time saved are substantial.
There is extensive literature describing the positive impact of conventional telemedicine modalities on access to health care globally [
The use of eVisits has grown in the last few years across North America [
eVisits were associated with high patient satisfaction when employed in primary care settings [
Perhaps one of the most significant outcomes we report is the reduced patient wait time-to follow-up. eVisits allowed the physician to see patients sooner than would be possible for an in-person encounter, thus increasing the availability of health care. The technology supporting eVisits also provided the ability to share imaging or echocardiographic findings with the patient in addition to sharing medical illustrations, enabling and facilitating patient education, understanding, and empowerment. eVisits also offer the ability to identify risks and patient vulnerabilities sooner, improve treatment adherence, and support behavioral and care interventions to improve speech, mobility, and enhance access to home care or community-based care or allied health services. Flexible scheduling allows physicians to be more productive with their time, enabling them to distribute their clinical activity to accommodate other commitments including teaching, research, and administration. In addition to increased productivity, using eVisit has the potential to address some of the significant contributors to physician burnout (including work and organizational factors), which can in turn have consequences on patient care and health care costs [
The eVisit offers the potential for a significant reduction in per capita costs for outpatient care. The estimated direct OOP cost savings for a single in-person visit is considerable. This could be much higher if accounting for multiple health care encounters. Our estimated OOP cost saving per visit is probably conservative; real savings would vary significantly based on the individual’s hourly wage, employment status, other personal factors, and visit characteristics.
Opportunity cost refers to the cost or money that the health care system could have allocated or used for similar or different interventions [
Some of the disadvantages of the eVisits relate to the technology itself. The service cannot be offered to patients who do not have an internet enabled device and/or sufficient internet connection speed, thus potentially limiting the access to home-based eVisits to patients with lower socioeconomic status. In addition, internet access and speed are limited in some geographic areas, especially in rural and remote communities. Moreover, patients with physical, cognitive, and language disabilities may find it hard to use the technology or navigate the appropriate software on their own. Another disadvantage is the inability to do an in-person clinical examination, limiting the utility of the eVisits in some clinical scenarios. However, the video-based examination has been shown to be reliable and valid [
The strengths of the pilot study include implementation of a successful eVisit program for outpatient follow-up in a specialty stroke clinic catering largely to a senior population. The combination of high degree of patient satisfaction with potential savings of both time and money holds promise for economically improving access to care. The mean time spent per eVisit, including the documentation of the clinical encounter, was 10 min, which is comparable with the time allocated for the physician-patient portion of a typical in-person clinical contact. We believe that our choice to perform a test eVisit before the physician-patient visit reduced the chance of communication technical difficulty and resulted in very successful physician eVisits with 5% (4/81) failure rate and 3% (2/81) no-show rate. This pilot study will inform the expansion of the eVisit project to other specialty clinics within the organization as the next phase.
Some limitations of the study include the limited sample size and pilot duration. The scope of the project was narrow, involving 1 specialty clinic. These limitations prevent broader generalizability. There is a potential for bias in assessing patient satisfaction as a result of using a brief telephone survey with nonprobability sampling. The economic analysis of outpatient costs, as well as opportunity cost for in-person care, needs to be corroborated in future studies across multiple organizations. The outpatient health care costing data may vary amongst different health care organizations.
The limited uptake of virtual care services such as eVisits by physicians was recently reported in a 2018 survey, highlighting the need for appropriate reimbursement or alternative payment models as well as improved technology, privacy and security guidelines, and support from clinician associations and governance bodies [
To address some of the limitations of eVisit,
eVisits were implemented successfully for an outpatient follow-up clinic for adult stroke patients in our pilot study. eVisits were well received by patients and consistent with a patient-centered care philosophy. eVisits have the potential to significantly transform the ambulatory clinic practice by addressing some of the barriers to care and improving patient experience, reducing per capita health care costs, and improving population health. Such a transformative change needs the involvement of health care professionals, health services researchers or economists, hospital leadership, clinician associations, and health system governance bodies at the regional and provincial levels to inform evidence-based practice guidelines and sustainable models of care. eVisits are scalable and could be expanded to additional specialty programs, a move that is underway at KHSC.
Definitions used for Time, Distance and Cost savings.
Volume of patients seen in the stroke prevention clinic during the pilot phase.
Distance and time savings for patients.
Ambulatory care costs for CACS codes (E751 and E752) in Ontario and Alberta for 2016/2017.
Comprehensive Ambulatory Classification System
Canadian Institute for Health Information
electronic visit
interquartile range
Kingston Health Sciences Centre
Ministry of Health and Long-Term Care
out-of-pocket
Ontario Telemedicine Network
substitute decision maker
The authors would like to thank Ms Maria Foss for her Secretarial assistance in coordinating the eVisits in the stroke prevention clinic.
This eVisit pilot project was supported by funding from the Department of Medicine, Queen’s University. The funding was required primarily for part-time secretarial salary support.
RA received internal grant funding for the eVisit pilot project from the Department of Medicine, Queen’s University.