Innovative virtual care delivery in a Canadian paediatric tertiary-care centre

Abstract

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children’s Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation.

Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

THE SYNERGISTIC CONTEXT OF VIRTUAL CARE AND COVID-19

The first paediatric virtual care visit may have occurred in 1897 when a physician wrote to the journal Lancet of their experience using the then-new telephone to reassure a worried parent that their child did not have croup (1). Over the years, virtual care saw growth due to improved technology including better internet connectivity, leading to innovative, convenient, and value-based health care (2). Benefits of virtual care include improved access, increased patient and caregiver satisfaction, cost savings, and an opportunity for flexible, culturally sensitive care (3). Barriers to implementation have included inadequate infrastructure and remuneration, and a lack of evidence-based guidance regarding appropriate contexts for in-person versus virtual care visits (4). During the COVID-19 pandemic, the need to preserve personal protective equipment (PPE) and minimize the spread of infection (5,6) led to the prioritization of eHealth infrastructure development and updated remuneration schedules to facilitate the rapid spread and adoption of virtual care delivery. The most striking change to virtual care during the pandemic has been the use of synchronous telemedicine as a replacement for in-person visits.

PAEDIATRIC VIRTUAL CARE IN CANADA

In our Canadian paediatric population, a desire to provide access to care, combined with a commitment to patient and caregiver safety, brought innovative health care approaches and national collaboration to evaluate the impact of the shift to virtual care. Much of this information-sharing has been done informally but the literature base is built with examples within paediatric diabetes (7), paediatric asthma (8), and emergency medicine (9). Opportunities to learn from each other are limited since structured evaluation has not routinely been a component of novel virtual care program implementation—particularly because of the rush to restructure care to satisfy patient needs during the pandemic. By sharing our pandemic pivot across diverse clinical areas, we hope to promote knowledge sharing and a cohesive path forward, with the goal of favourably impacting Canadian paediatric health outcomes.

PANDEMIC PIVOT TO VIRTUAL CARE AT A PAEDIATRIC TERTIARY-CARE CENTRE

The Children’s Hospital of Eastern Ontario (CHEO) is an academic, tertiary-care centre that quickly adapted to virtual care delivery with a focus on sustainability. During the 2020 and 2021 pandemic waves in Ontario, approximately 70% of ambulatory visits were virtual with some services seeing over 90% of their patients virtually. Rapid leveraging of digital health, innovations in care delivery models and operational support allowed this new platform for care delivery—primarily as video visits (versus telephone)—to flourish. In 2019 CHEO was already developing a telehealth plan as part of the ‘Faster Access’ strategic goal (10). Pilot projects were completed in endocrinology and mental health including the Ontario Telehealth Network (OTN) Partner Video Program (11). While favourable outcomes were seen in patient and provider satisfaction (12), concerns were raised regarding care delivery integration and sustainability. For example, visits were booked on an independent platform, requiring its own log-in and display screen, and patients were required to download supporting software to connect. Lessons learned included the importance of integrating the virtual platform into the electronic health record (EHR) and making virtual visits available to all patients, regardless of whether they were active on the patient portal. These factors guided the development of virtual care delivery programs currently in use at our hospital, including family-centred inpatient rounds, emergency department visits, mental health consultations, group therapy, and ambulatory care.

OUR VIRTUAL CARE DELIVERY PROGRAMS

Inpatient medicine

Family-centred rounds (FCR) bring together the multidisciplinary care team to ensure a shared understanding of patients’ current health status and plan of care. Typically, FCR takes place in or outside a patient’s room, however, with the onset of the pandemic, physical distancing, and preservation of PPE were required. In April 2020, a multidisciplinary team—including patients and caregivers—came together to virtualize our established in-person FCR process (Figure 1) and embarked on a 4-month pilot that resulted in a successful care model that has been sustained for over a year (13). A rigorous evaluation of the virtual FCR (vFCR) process and associated technology is underway.

Figure 1.

The virtual family-centered rounds process. Rounding schedules are created for each unit by unit clerks. Patients/caregivers are invited to participate in vFCR during nursing’s morning assessment. Two tablets with headsets are set up on a rolling table - one for the nurse and one for the patient/caregiver. Physician teams meet in conference rooms or personal offices – laptop computers or mobile devices are used to join vFCR. Rounds begin at 09:30. The nurse provides the patient/caregiver with a tablet. The attending/senior resident leads rounds following FCR standard content. Once the round is complete, the nurse cleans the tablet + headsets and moves to the next patient or next nurse on the rounding schedule. Tablets are returned to the clerk at the end of rounds for cleaning and storage. Feedback and troubleshooting of issues are encouraged daily.

Building on the vFCR infrastructure, inpatient virtual care services were formalized in May 2020 to accommodate virtual consultations for inpatients, when appropriate. Piloting in mental health, this virtual workflow resulted in favourable patient and caregiver feedback (e.g., the easier establishment of rapport without PPE covering faces, less anxiety) which facilitated expansion to subspecialty services. Uptake was slow initially, likely largely due to the inability to integrate virtual visits within the inpatient encounter, but education, stakeholder engagement, equipment enhancement, and support resources (e.g., standard work) have improved adoption. By October 2020, this model had expanded to all inpatient areas and was adapted to support inpatient multidisciplinary team meetings and follow-up visits.

Emergency medicine

Emergency departments (ED) worldwide experienced a significant decrease in visits at the onset of the pandemic. Although physical distancing, closure of schools, and cancelled recreational activities likely decreased the burden of viral illness, it was speculated that the decrease was also driven by a fear of contracting COVID-19 in the hospital. Paediatric EDs reported delayed presentations of acute illness associated with increased morbidity (14,15). Our team developed the first Virtual Pediatric ED in Canada (V-PED) to give families an alternative to in-person ED care for urgent problems. This platform re-imagined ED care, employing a self-referral model where caregivers determine whether V-PED is appropriate for their child by reviewing an online checklist of higher acuity conditions requiring in-person care. From May 4, 2020 to early November 2021, there have been 7,205 V-PED visits. Monthly audits demonstrate very low rates of unplanned ED visits or admissions within 72 hours of V-PED care. V-PED patients complete a voluntary post-care survey to ensure the platform is meeting families’ needs. On average, 90% of families each month have indicated they would have sought in-person ED care if V-PED was not available. The V-PED model could help alleviate ED crowding and improve flow in the post-pandemic era. Future research should investigate the impact of V-PED care on ED crowding and the cost-effectiveness of this care model.

Ambulatory care

By April 2020, shortly after the onset of the pandemic, 75% of ambulatory care visits were virtual with certain clinics maintaining >95% of pre-pandemic patient volumes. As restrictions eased, this percentage dropped and has hovered around our operational target of 50%. While telephone visits were the predominant modality initially, within a few months, most virtual visits were being conducted via video and this has been maintained. As of November 2021, 46% of ambulatory care visits are virtual (75% video, 25% telephone). Video visits enable modified physical exam manoeuvres and facilitate multi-disciplinary care, including streamlined learner involvement. We predict remuneration of video care will be more sustainable than telephone visits as billing codes for video visits were already live in several provinces pre-pandemic and our health care system funding may not be capable of sustaining the temporary telephone codes. Increased adoption of our patient portal has facilitated the efficient provision of asynchronous virtual care with secure messaging replacing phone calls and visits. Of our total patient care encounters to date in 2021, 50% were asynchronous virtual care, 27% were in person and 23% were synchronous virtual care. Importantly, one asynchronous encounter could capture several points of contact regarding one topic.

Distinct ambulatory care areas have adapted in unique ways to prioritize a ‘virtual-first’ approach while maintaining care volume and quality, ensuring that critical components of a visit that cannot be done virtually are not omitted. Rapid restructuring of our diabetes clinic resulted in a shift to a sustainable ‘virtual-first’ approach. From March until July 2020, the multi-disciplinary team met daily via Zoom meetings to troubleshoot, brainstorm, and strategize care delivery adaptations to meet patient needs, predominantly virtually. Restructuring care for approximately 800 youth with diabetes resulted in 90% virtual follow-up visits supplemented by drive-thru point-of-care-testing (POCT) hemoglobin A1C (A1C) clinics (Figure 2), pre-visit instructions, patient portal promotion (53% active), pharmacy auto-faxing, printer mapping, and a quality improvement evaluation embedded into the clinical workflow. The A1C clinic runs monthly accommodating three patients every 15 minutes using two POCT analyzers. Results from patient/caregiver experience evaluation were universally favourable (16). Other tangible outcomes included: follow-up order re-design to capture suitability of virtual versus in-person care and allow for quick conversion to virtual due to isolation requirements; an educational framework for learner involvement; staff role re-assignment to facilitate minimal on-site staff; primarily virtual new-onset diabetes teaching; 25% increase in insulin pump starts/month using hybrid virtual/in-person/group education. Results from a quality improvement evaluation (analysis underway) of the patient, caregiver, and provider experience (including satisfaction and perceived quality of care) and process of care measures will shape how virtual care is integrated into our overall diabetes care.

Figure 2.

Diabetes Drive-Thru A1C Clinic.

Mental health

With the onset of the pandemic, CHEO’s Mental Health Program quickly converted care delivery to virtual platforms, initially via telephone and OTN, and subsequently via EHR-integrated videoconferencing—providing 91% of 2020 outpatient appointments this way. Data obtained between March and May 2020 showed that over 90% of patients and caregivers would use virtual care again and recommend it to others while 92% of providers felt that they were able to build rapport, provide safe and satisfactory patient care virtually.

To address the need for group psychotherapy sessions, a critical component of care for our most vulnerable patients, virtual group visits were implemented. Subsequently, other clinical areas, such as Rehabilitation and Development were able to leverage these workflows and modify them to meet their own needs.

Eliminating in-person care was not feasible for all patients. For example, patients taking psychotropic medications require vital signs assessment to ensure safety. Thus, the novel ‘Vitals Clinic’ was created, where patients would undergo a brief in-person assessment by a nurse in a safe and convenient environment. As of November 2021, we have completed 514 visits across 51 clinic days (an average of 10 clients a day).

Finally, in an ongoing effort to reduce patient transfers from community ED to CHEO, the Mental Health Program developed and implemented virtual emergency psychiatric consultations for our community hospitals. Between April 2020 and November 2021, 236 patients received virtual psychiatric care through this program, often facilitating safe discharge home and preventing transfer to CHEO.

FACILITATORS AND BARRIERS TO IMPLEMENTING A SUSTAINABLE VIRTUAL CARE CULTURE AND MODELS

Innovation and creativity drove the development of clinically diverse virtual care programs at CHEO that we expect will persist long after the pandemic is a memory. While each model has adapted uniquely to accommodate their unique patient populations, facilitators to their success are shared across contexts (Table 1). Our experience has been within a paediatric tertiary-care centre, but most facilitators are transferable to a private practice setting. For example, providers can work with their EHR vendors to implement digital health tools to support virtual care.

Table 1.

Facilitators to successful implementation of virtual care delivery

Domain	Facilitator	Details/Description
Governance Structure	Virtual Care Leadership Team	Membership: Information Services Leads, Analyst, Operational Leads/Managers, Providers, Human Factors Specialist Routine Consultation with Family and Youth Forum Consultation, Communications Workplan informed by current state analysis (patient/provider survey data, data review, divisional check-ins) and operational targets
Leveraging Digital Health	Zoom Integration	Provider link accessible within electronic health record (EHR) Allows multidisciplinary visits an opportunity for several health care professionals to attend together or sequentially using just one link Automated link delivery for patients/families not active on patient portal Zoom integrated workflow promoted as preferred platform but other options supported (e.g., telephone)
	Patient Portal Ramp-Up	Streamlined activation, improved functionality including universal access to secure messaging, note sharing
	E-faxing	Prescription for medication and supplies faxed automatically within EHR
	Follow-Up Visit Type	Discrete capture of preferred/required follow-up visit type (virtual vs. in-person) to capture provider and patient preference and allow for rapid conversion as needed
	Dashboards	Weekly metrics on internal website Daily metrics with EHR
Tools and Resources	Internal Website Improvements	Tip sheets, guiding principles, links to resources, training videos
	External Website Improvements	Virtual care resources
Operational Support	Virtual Care Clerk	To support families connecting to virtual care visits
	Virtual Care e-hub	To support providers arranging for virtual care visits/troubleshooting
Innovation	Unique clinic-specific adaptation	e.g., ‘Drive-thru’ A1C clinic; ‘drive-up’ Vitals clinic, ‘auxology’ clinics where patient has various measurements done including height, weight, body proportions, pubertal assessment
Stakeholder engagement	Informal and formal evaluation of individual experience	Multidisciplinary meetings aimed at troubleshooting and quality improvement Qualitative and quantitative evaluation of provider, patient, caregiver experience.
Attention to teaching requirements	Redesigning trainee role Simplified connectivity and technical workflow	Clinic-specific workflows that ensure adequate exposure (balance of virtual vs. in-person) Preferential use of video visits (Zoom integrated in EHR) to allow trainee attendance with or without staff. Optimization of ‘stop video’ and ‘mute’ functions to allow case review within encounters.

Although often an ideal substitute for in-person care, there are limitations to virtual care provision including, but not limited to, the lack of a physical examination, inability to discern non-verbal cues, inability to ensure privacy, connectivity issues, and inequitable access which can impact the care quality and result in adverse events (17). Ensuring that new technologies do not fuel a digital divide and increase health disparities (18) is crucial.

A DATA-DRIVEN VIRTUAL CARE FUTURE

COVID-19 restrictions are likely to remain in place, in some form for the foreseeable future. Moreover, we have clearly heard from patients, families, and providers that virtual care should continue post-pandemic. Indeed, there is no ‘going back’: optimization of virtual care aligns with provincial and national healthcare priorities (4,19). Thus, the question of the ongoing integration of virtual care into our care delivery models is not a matter of why, but how.

As we face the opportunity to embed virtual care into our usual care delivery processes, we recognize the lack of a common, nationally relevant, framework to evaluate and optimize this new model across our hospital and within all paediatric care models including non-hospital-based care which serves the bulk of our paediatric population. Most literature to date has focused on the individual experiences of patients, families/caregivers, and providers (20,21) but the impact of virtual care on paediatric outcomes remains largely unknown and there is a paucity of evidence regarding its equity, quality, safety, and cost-effectiveness. A lack of validated evaluation tools, consistent terminology, and user-friendly evaluative frameworks make comparisons difficult and data challenging to appraise. Although several clinical programs at CHEO, and other paediatric hospitals across Canada, are evaluating virtual care (7,9), a coordinated and comprehensive evaluation of virtual care that includes community-based care has not been performed.

Internationally, paediatric telehealth programs have historically grown individually rather than cohesively, which makes it difficult to evaluate their impact in an evidence-based manner (22). In the absence of data-driven recommendations, expert groups have convened to provide guidance on how to safely incorporate virtual care into their care delivery models (23–25).

In Canada, our vastly different health care context means that a Canadian-specific framework will be most beneficial in informing the care we deliver.

CHEO’s Virtual Care Evaluation Group (VCEG) has been assembled to guide and develop our evaluation approach for paediatric virtual care that is integrated within CHEO’s virtual care strategy and aligned with the strategic plans of CHEO and CHEO Research Institute (26,27). Group membership includes virtual care leads and stakeholders from paediatrics, surgery, mental health, our autism program, the research institute, medical education, quality improvement, eHealth/information services, human factors design, and our Family Leader Program. The VCEG has identified key deliverables, including the development of an evaluation framework for virtual care. Guided by an existing American paediatric framework (25), and emphasizing the six care quality elements identified by Health Quality Ontario (28), our framework will enable meaningful national and international comparisons. Importantly, recognizing that the reliance on digital tools for health care has the potential to result in inequities in access to care (29), the VCEG has partnered with CHEO’s Equity Diversion Inclusion and Indigeneity Task Force to ensure that attention to equity and health disparities are integrated into the proposed framework at every level.

We believe this framework is essential to enable comprehensive evaluations of paediatric virtual care models in a variety of contexts to support ongoing research and quality improvement work in Canada. Moreover, it should help yield meaningful results to inform health care delivery models, support requests for clinical program funding, and can be leveraged to respond to research and clinical opportunities to explore additional innovations in virtual care delivery and ultimately help ensure the best health outcomes for children, youth, and families in Canada.

COVID-19 has expedited the evolution of virtual care in paediatrics and is increasingly accepted as the ‘new normal’ (30,31). We now have the opportunity to carefully create a national vision for how to embed virtual care within our care delivery models. By sharing our experience, we hope to inspire paediatricians across Canada to see opportunities for virtual care models in their own practices, leverage this technology to make health care more accessible and relevant to the children and families they care for and embed systematic evaluation into program implementation to ensure that meaningful results inform future care delivery.

ETHICS APPROVAL

Not applicable.

FUNDING

There is no funding to declare specific to this manuscript.

POTENTIAL CONFLICTS OF INTEREST

The authors declare the following financial interests/personal relationships, none of which are felt to be real competing interests: EBG is a site co-Investigator (co-I) for the Medtronic study entitled ‘Multi-center, Randomized, Parallel, Adaptive, Controlled trial in Adult and Pediatric Patients with Type 1 Diabetes Using Hybrid Closed Loop System and Control (CSII, MDI, SAP) at Home’. Medtronic provided funds to cover the cost of supplies and research staff time for this study, but investigators did not receive payment. EBG is an elected (by peers) member of the International Epic (Wisconsin) (electronic health record) Specialty Steering Board, which is comprised of a group of 12 paediatric endocrinologists who work together to action improvements to the electronic health record to facilitate better patient care. This is an unpaid position. MBu and WJK declare a competitively funded research grant from Children’s Hospital Academic Association for Phase 2 of the Virtual-Family-Centered Rounds study, as Principal Investigator (PI) and co-I respectively. Payment made to institution for grant. MBh declares competitively funded research grants from Physician Services Incorporated (PSI) Foundation (PI, co-PI), COVID-19 Ontario Rapid Research Fund (PI) and CIHR (co-I). Payments made to institution for all grants. MBh received conference presentation honoraria from: Pediatric Sedation Outside the Operating Room, Society for Pediatric Sedation, American Society for Dental Anesthesia, and PEM Fellows National Review Course. There are no other disclosures. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

SUPPLEMENT FUNDING

This article is part of a special supplement on the impact of the COVID-19 pandemic on children and youth. Production of this supplement was made possible through a financial contribution from the Public Health Agency of Canada. The views expressed herein do not necessarily rep­resent the views of the Public Health Agency of Canada.