The potential socio-economic impact of telemedicine in Canada

Short abstract

This study examined the potential impact in Canada of continued, long-term use of telemedicine. Researchers found that, alongside the benefits from tools such as telemonitoring and digital health records, widespread use of teleconsultations could lead to significant benefits for patients, the economy and wider Canadian society. The findings directly contribute to the evidence base in telemedicine and virtual healthcare more generally.

Abstract

Telemedicine has been available in Canada for a while but its uptake before the COVID-19 pandemic has been slow. The pandemic has since changed how people in Canada access healthcare by hastening digital transformation in the sector. Pre-pandemic, Canada was behind its international peers in its use of telemedicine. Now, many patient consultations, both primary and specialist, are conducted virtually.

RAND Europe researchers examined the potential impact in Canada of continued, long-term use of telemedicine, which can include the use of “smart” devices to conduct medical tests, the digital storage and sharing of medical records, and real-time tele-consultations between healthcare providers and patients. They looked at the quality, access and cost of telemedicine, the barriers that have led to its relatively slow adoption, and what the economic effect would be of an increase in uptake.

The study found that, alongside the benefits from tools such as telemonitoring and digital health records, widespread use of teleconsultations could lead to significant benefits for Canadian patients, the Canadian economy, and wider Canadian society. The findings directly contribute to the evidence base in telemedicine and virtual healthcare more generally.

Telemedicine (TM) has the potential to improve access to healthcare for Canadians and offers the prospect of significant benefits to the Canadian economy and society. Amid an aging population and a rise in non-communicable diseases, the sustainability and financial viability of the healthcare system is a major concern for policy and decision makers in most developed countries, including Canada. Canada has experienced a steady rise in health expenditure over the years, which has triggered a desire to find solutions to reduce the cost of providing healthcare, while simultaneously maintaining—or even improving—the quality and ease of access to care. There has been increasing interest among decision makers and healthcare providers to explore the application of telemedicine to improve patient outcomes and to meet the growing demand for services at a sustainable cost.

What Is Telemedicine?

Telemedicine is characterised by the use of information and communication technologies to deliver healthcare over distance. Currently, three types or modes of telemedicine are used across countries: (1) telemonitoring; (2) store and forward (SAF); and (3) interactive telemedicine.

Telemonitoring entails the use of mobile devices and technology platforms to conduct medical tests and communicate the results to healthcare professionals in real time. SAF refers to the digital storage and sharing of health records; it is similar in nature to telemonitoring but is suitable for less time-sensitive data, allowing efficient access to patient health records across a range of different healthcare providers. Interactive telemedicine involves direct real-time communication between healthcare providers and patients using smart phones, video conferencing or other technology platforms. As technological change progresses quickly, the ability of telemedicine to provide access to healthcare is constantly changing and new applications are emerging (e.g. through the application of artificial intelligence).

Rationale for the Study and Research Questions

Globally, the COVID-19 pandemic has led to rapid digital transformation across many business sectors. It has also changed, at least temporarily, how people access some healthcare, with many primary and specialist care consultations moving to virtual appointments. While telemedicine has been in use in Canada for some time, its uptake before the pandemic lagged behind other countries such as the United States and the United Kingdom. For instance, in 2019, only 22 per cent of Canadian primary care facilities reported offering patients the option to directly communicate by email or secure website about a medical question, compared to 66 per cent in the United Kingdom and 77 per cent in the United States.

However, at the peak of the pandemic, almost 60 per cent of consultations between patients and primary care physicians in Canada were held virtually. While the initial surge in the uptake of telemedicine has ebbed, depending on the stringency of the physical distancing measures in place, between 28 per cent and 41 per cent of consultations were still held remotely between late 2020 and early 2021. The key question is whether the recent appreciation for telemedicine in the delivery of care will persist, and to what extent the right policy conditions could support a more permanent increase in the usage of telemedicine in the future.

This study aims to gather evidence surrounding the use of telemedicine by addressing the following four main research questions:

• 1.What is known from existing research about the potential societal impacts associated with the adoption of telemedicine?
• 1a.What is the evidence about the quality of care delivered through telemedicine compared to standard in-person care across different clinical areas?
• 1b.What is the evidence about the ability of telemedicine to provide better access to care?
• 1c.What is the evidence about the relative cost implications associated with the usage of telemedicine?
• 2.What are the quantifiable impacts of telemedicine usage for Canadian society?
• 3.What are the existing barriers challenging the adoption of telemedicine in Canada?
• 4.How can the existing barriers be addressed to unlock some of the potential associated with the increased use of telemedicine?

Reviewing the Existing Evidence: The Potential Impacts of Telemedicine on Quality, Access and Cost of Care

To address the first research question, we conducted a targeted review of systematic literature reviews to assess the existing evidence on how telemedicine impacts (1) quality of care; (2) access to care; and (3) costs of providing care.

Impact on Quality of Care

Regarding patient outcomes (e.g. mortality rates, health-related quality of life), there is evidence that telemedicine can be at least comparable, or even superior, to in-person care for the management of chronic diseases, including diabetes and heart failure. In other clinical areas, such as mental health, there is evidence that the use of telemedicine (e.g. through remote consultations with a mental health practitioner) leads to similar patient outcomes compared to face-to-face consultations, although more research is needed. It is important to highlight that the evidence suggests replacing face-to-face consultations with remote consultations in general will not be suitable for all types of patient needs, and there are many situations that require an in-person meeting with a healthcare practitioner to maintain the quality of care. In addition, teleconsultations may not be suitable for different types of patients, including vulnerable or hard-to-reach individuals suffering from a variety of health conditions. There is also evidence to suggest that teleconsultations are more efficient when there is an already established patient–physician relationship to build on the continuity of care.

Impact on Access to Care

The use of telemedicine has relatively high acceptability among patients, and leads to good patient satisfaction, as it can make it easier and more convenient for patients to engage with their healthcare providers, leading to more flexible and timely care. Most Canadians are in favour of virtual healthcare visits, with 40 per cent of those in favour reporting that they even would be willing to switch to virtual clinician visits for most of their healthcare needs; this figure has likely increased during the COVID-19 pandemic. The reduced need to travel and the potential reduction in waiting time are important convenience factors for patients. Furthermore, the existing evidence suggests that telemedicine has the potential to improve access to healthcare for Canadians with unmet healthcare demands. As distance and travel time between patients and healthcare providers can limit access to care, telemedicine could be particularly beneficial for patients in remote and medically under-served northern and rural communities who generally experience reduced access to care, and who are typically required to travel long distances to obtain health services. Indeed, a recent study estimated that replacing 4 per cent of primary care visits with remote consultations saves the Canadian population 8.8 million hours that would have been spent travelling or waiting at a primary care providers’ premises. Therefore, providing and easing access to healthcare could lead to positive well-being and productivity outcomes for Canadians.

Impact on Healthcare Costs

With regards to healthcare cost savings, the evidence from the existing literature on the potential relative cost implications of specific telemedicine applications compared to standard care is mixed and inconclusive. For instance, while many telemedicine interventions would require some upfront investment into new technologies (i.e. fixed costs), if they lead to lower variable costs of treatment over time, they will become cost-saving in the medium- to long-run. But existing research often does not consider well the trade-off between short- and long-term cost. Considering the health system more broadly, existing evidence suggests that the use of telemedicine could be associated with more efficient modes of consultations, fewer missed appointments and decreased use of emergency services—all resulting in healthcare cost savings. Telemedicine can also help improve the efficiency of clinical workflows in healthcare organisations, which can improve care quality and patient safety. Given that a large part of healthcare spending is related to labour cost, the adoption of telemedicine could drive healthcare cost savings.

This Study Estimates the Value of Telemedicine in Terms of 1) Time Saved; 2) Fewer Emergency Room Visits and Missed Appointments; and 3) Greater Access to Physicians

Addressing the second research question, this study monetised three impacts: (1) the (economic) value of time saved by patients not having to travel and wait for consultations; (2) the direct healthcare cost savings associated with fewer emergency department visits and fewer missed appointments; and (3) the well-being value of providing access to a primary care provider.

 

Impact One: A more permanent increase in the use of telemedicine in Canada compared to pre-COVID-19 levels is estimated to be associated with an economic value of time saved worth up to CAD 5bn per year.

This study quantifies the economic value of time saved by patients not having to travel for consultations with a primary care provider. To that end, the potential hours saved under different scenarios of telemedicine usage for primary care visits are calculated, and then the hours saved are applied in a macroeconomic computational general equilibrium (CGE) model based on the Canadian economy. Some of the time saved will have a positive effect on productivity (e.g. through fewer working hours lost), and some of the additional time will increase available leisure time. Thus, the economic value of time saved has two components: (i) the added gross domestic product (GDP) if people spend more time at work; and (ii) the value of added leisure in economic terms.

The value of time saved is assessed through four different telemedicine usage scenarios. These differ in their assumption of how many primary care consultations would be held remotely through teleconsultations (i.e. 5 per cent, 10 per cent, 25 per cent and 50 per cent) and are then compared against a baseline scenario corresponding to the pre-pandemic usage rate of teleconsultations in primary care (4 per cent). For example, a 10 per cent usage scenario would resemble the National Health Service in England's “Long-Term Plan” to transform outpatient care using technology, which aims to substitute approximately 10 per cent of face-to-face appointments with remote consultations. At the other end of the scenarios, 50 per cent would represent usage levels observed during the COVID-19 pandemic, an upper bound of the number of consultations that could be replaced through telemedicine, at least in the short- to medium-term.

Panels A and B of Table 1 summarise the monetised economic values of time saved based on the increase in GDP and the additional economic value of leisure under the four different telemedicine usage scenarios. The values are provided for Canada as a whole and broken down by regions. For example, an increase to 50 per cent teleconsultations compared to a baseline scenario of 4 per cent is estimated to be associated with an increase in economic value by about CAD 5bn per year, which corresponds in terms of its value to about 2 per cent of Canada's total annual health expenditure. (Note that the rise in the value of time saved, associated with an increase in the usage of telemedicine, exhibits non-linear behaviour whereby an increase from 5 per cent to 50 per cent teleconsultations in primary care settings will not raise the value by the same proportion. The intuition behind this relates to a labour-leisure substitution feature built into the economic model. Individuals make decisions about how much of their additional time saved is to be allocated towards increasing their labour-hours or leisure-hours, and these activities do not have the same economic (monetary) value in welfare. At lower telemedicine usages, individuals proportionately allocate more of their additional time saved towards labour. But as telemedicine usages rises, the additional marginal time saved is gradually added-on to leisure. Because labour and leisure provide different measures of welfare (one through GDP and one through pure leisure), our results exhibit non-linear behaviour.)

Table 1.

Economic Value of Time Saved—Baseline Scenario Pre-COVID-19 Levels of Teleconsultations

	Telemedicine usage scenario (CAD, million, per year)
	5 per cent	10 per cent	25 per cent	50 per cent
Panel A. GDP only
Canada	64.00	384.06	1,344.75	2,947.62
Newfoundland and Labrador	0.98	5.87	20.55	45.05
Prince Edward Island	0.18	1.10	3.84	8.42
Nova Scotia	1.29	7.74	27.11	59.43
New Brunswick	1.06	6.36	22.28	48.83
Quebec	12.75	76.53	267.95	587.33
Ontario	24.70	148.23	519.01	1,137.65
Manitoba	2.04	12.27	42.96	94.17
Saskatchewan	2.30	13.79	48.27	105.81
Alberta	9.78	58.66	205.39	450.20
British Columbia	8.56	51.37	179.87	394.27
Territories	0.32	1.90	6.65	14.57
Panel B. GDP plus value of leisure
Canada	108.83	653.03	2,286.37	5,011.03
Newfoundland and Labrador	1.66	9.98	34.94	76.58
Prince Edward Island	0.31	1.87	6.53	14.32
Nova Scotia	2.19	13.17	46.10	101.04
New Brunswick	1.80	10.82	37.88	83.02
Quebec	21.68	130.12	455.57	998.47
Ontario	42.00	252.04	882.44	1,934.04
Manitoba	3.48	20.86	73.04	160.08
Saskatchewan	3.91	23.44	82.07	179.87
Alberta	16.62	99.74	349.20	765.35
British Columbia	14.56	87.35	305.82	670.26
Territories	0.54	3.23	11.30	24.78

Notes: Table reports monetised benefits of telemedicine across different usage scenarios (5 per cent; 10 per cent; 25 per cent; 50 per cent). Estimated are the GDP value of time saved and the economic value of additional leisure time associated with a reduction of time spent visiting a primary care provider. The reported values by scenario are compared against a pre-pandemic baseline scenario of 4 per cent adoption of teleconsultations. We estimate that if the proportion of primary care consultations in Canada that are held remotely increases to 5 per cent (from a 4 per cent baseline), the value of time saved in GDP terms is CAD 64m per year. Considering the economic value of leisure as well, this increases to CAD 109m per year. An increase to 10 per cent remote consultations (from a baseline of 4 per cent) is estimated to result in an increase of Canada's GDP by CAD 384m per year. Considering additionally the economic value of leisure, this value increases to CAD 653m per year.

Impact Two: A more permanent increase in the use of telemedicine in Canada could be associated with fewer unnecessary emergency care visits and missed appointments, and be worth up to CAD 147m in direct healthcare cost savings per year.

By using four different telemedicine usage scenarios (i.e. 5 per cent, 10 per cent, 25 per cent and 50 per cent), this study calculates the direct healthcare cost savings that could result from fewer emergency department visits and fewer missed appointments if teleconsultations could be offered to patients. Each year a relatively large proportion of Canadians use a hospital emergency department for visits that could appropriately be treated through a regular primary care provider (e.g. General Practitioner [GP] or family doctor). Care provided in emergency care for the same condition tends to be more expensive than care provided in primary care settings. Furthermore, every year a relatively large number of appointments with clinicians are missed. Using evidence suggesting that the option of teleconsultations could lead to fewer missed appointments, we calculate the potential related direct healthcare cost savings offered by an increased usage of telemedicine. (With regards to emergency care visits, we assume that a proportion of all unnecessary emergency department visits could be replaced with remote consultation [e.g. cases where the patient states the visit was not a real emergency but there was no other option available]. But even among these unnecessary emergency care visits we assume through the four different telemedicine usage scenarios that not all non-emergency visits can be treated remotely and that some patients will continue to prefer face-to-face consultations despite being offered a remote consultation. That is, we quantify the direct healthcare cost savings associated with substituting between 5 per cent and 50 per cent of unnecessary emergency visits with remote consultations. With regards to missed appointments, we assume that a proportion [5 per cent to 50 per cent] of missed appointments would not have occurred if the patient would have had a remote consultation instead of a face-to-face consultation.)

Panel A and B of Table 2 summarise the potential direct healthcare cost savings under the four different telemedicine usage scenarios. The values are provided for Canada as a whole and broken down by regions. We estimate that if 50 per cent of unnecessary emergency department visits or missed appointments could be averted through offering teleconsultations to Canadians, the Canadian healthcare system would save up to CAD 89m and CAD 58m as a result of fewer emergency room visits and missed appointments, respectively. (Note that both the estimated cost savings from fewer emergency department visits and fewer missed appointments should be interpreted as positive impacts that had not been materialised before the pandemic. That is, while about per cent of all primary care consultations have been held remotely before the pandemic, there is no information about the number of averted unnecessary emergency visits and missed appointments associated with this pre- pandemic baseline levels of teleconsultations. Therefore, we calculate the additional healthcare costs saved on top of this unknown number of emergency visits or missed appointments that may have already been saved before the pandemic.)

Table 2.

Estimated Direct Healthcare Cost Savings Associated with Fewer Emergency Department Visits and Fewer Missed Appointments

	Telemedicine usage scenario (CAD, million, per year)
	5 per cent	10 per cent	25 per cent	50 per cent
Panel A. Fewer emergency department visits
Canada	8.94	17.88	44.71	89.42
Newfoundland and Labrador	0.33	0.66	1.65	3.29
Prince Edward Island	0.07	0.14	0.34	0.69
Nova Scotia	0.40	0.79	1.99	3.97
New Brunswick	0.43	0.86	2.16	4.32
Quebec	1.35	2.70	6.74	13.49
Ontario	3.83	7.67	19.17	38.34
Manitoba	0.33	0.66	1.65	3.29
Saskatchewan	0.31	0.62	1.55	3.10
Alberta	0.78	1.55	3.88	7.76
British Columbia	1.08	2.17	5.41	10.83
Territories	0.03	0.07	0.17	0.34
Panel B. Fewer missed appointments
Canada	5.80	11.59	28.99	57.97
Newfoundland and Labrador	0.08	0.16	0.41	0.82
Prince Edward Island	0.01	0.03	0.06	0.13
Nova Scotia	0.09	0.19	0.47	0.95
New Brunswick	0.10	0.21	0.52	1.04
Quebec	1.32	2.64	6.61	13.21
Ontario	1.88	3.76	9.41	18.82
Manitoba	0.23	0.46	1.14	2.28
Saskatchewan	0.15	0.30	0.76	1.51
Alberta	1.07	2.14	5.35	10.69
British Columbia	0.84	1.67	4.18	8.37
Territories	0.01	0.03	0.07	0.15

Notes: Table reports monetised benefits of telemedicine across different usage scenarios (5 per cent; 10 per cent; 25 per cent; 50 per cent). Estimated are potential direct healthcare cost savings associated with a reduction of emergency department visits and fewer missed appointments if a remote consultation could have been offered to help the patient. While 4 per cent of all primary care consultations were held remotely before the pandemic, there is no information about the number of averted unnecessary emergency visits and missed appointments associated with this pre-pandemic baseline level of teleconsultations. Therefore, we calculate the additional healthcare costs saved on top of this unknown number of emergency visits or missed appointments that may have already been saved before the pandemic.

Impact Three: Providing access to a primary care provider is associated with positive well-being effects worth up to CAD 611m per year.

At least 3 per cent of Canadians report that they do not have a regular primary healthcare provider available in their local area. This not only has potentially direct negative consequences for their health, but also for their wider well-being. This study applies a valuation method that has been emerging in the scientific literature to calculate the well-being effects of things or events that do not have a direct market value, such as feelings or states of health. The approach is commonly referred to as the “life satisfaction” or “well-being valuation” approach, and in essence measures the monetary value that an individual would have to be compensated with to have the same level of life satisfaction in the absence of a negative factor, such as not having a primary care provider available. In the realm of economic appraisal for infrastructure projects it has in recent years become increasingly important to consider wider social value, and not only direct financial value.

The well-being effects of providing access to a primary care provider are assessed through four different telemedicine usage scenarios (5 per cent; 10 per cent; 25 per cent; 50 per cent). For example, a 5 per cent usage scenario assumes that of those individuals that report not having a primary care provider available in the local area, 5 per cent of those would be provided access to a primary care provider through remote consultations. By assuming that only a proportion (e.g. between 5 per cent and 50 per cent) of individuals without access to a primary care provider could be helped through TM, we assume that even if teleconsultations would be available to them, not every individual would prefer them compared to traditional face-to-face consultations.

Table 3 summarises the aggregated monetised value of increased well-being that could be achieved by providing access to a primary care provider for those that report not having one in their local area.

Table 3.

Monetised Total Value of Well-Being Associated with Providing Access to Healthcare Providers, for Those Without Access, Through Telemedicine

	Telemedicine usage scenario (CAD, million, per year)
	5 per cent	10 per cent	25 per cent	50 per cent
Canada	61.1	122.3	305.7	611.4
Newfoundland and Labrador	2.4	4.9	12.2	24.4
Prince Edward Island	0.5	1.0	2.5	5.0
Nova Scotia	1.5	3.0	7.5	15.1
New Brunswick	1.2	2.5	6.1	12.3
Quebec	18.7	37.5	93.7	187.3
Ontario	15.2	30.3	75.8	151.6
Manitoba	2.8	5.6	14.0	28.0
Saskatchewan	2.5	4.9	12.3	24.6
Alberta	5.6	11.2	28.0	55.9
British Columbia	7.8	15.6	38.9	77.9
Territories	2.9	5.9	14.7	29.4

Notes: Table reports monetised benefits of telemedicine across different usage scenarios (5 per cent; 10 per cent; 25 per cent; 50 per cent). Estimated are potential monetised aggregated values of well-being associated with providing access to a primary care provider for individuals that currently report not having access to a primary care provider in their local area. The reported values by scenario are compared against a pre-pandemic baseline scenario of no access to a primary care provider through the increased offering of teleconsultations.

We estimate that if 5 per cent were provided access through teleconsultations, the aggregated well-being value across Canada is CAD 61m per year, which increases to CAD 611m per year if we assume that 50 per cent of those without a primary care provider could be helped through remote consultations.

Limitations of the Economic Analysis

It is important to highlight the fact that the estimated economic values of an increase in the use of telemedicine reported in Tables 1 to 3 do not consider the potential costs to achieve these monetised positive impacts. That is, they are not compared against the potential cost to achieve a certain level of telemedicine usage. However, it is likely that a modest increase in the usage rate of telemedicine (e.g. to 10 per cent) would not necessarily lead to a large increase in tangible costs. This is because many Canadians have already used some form of virtual consultation through phone, email or videoconferencing during the course of the pandemic. It is also important to highlight that in the economic analysis, where parameters have been used that have a certain degree of uncertainty attached, we use the most conservative parameter assumptions (e.g. for the average travel distance to a healthcare facility, or the type of consultations that can be replaced with teleconsultations). Furthermore, there are a number of potential benefits associated with the uptake of telemedicine that have not been monetised, such as improvement in quality of care or the potential efficiency gains in clinical workflows in healthcare organisations and within the health system more generally, which could result in major cost savings. There are also potential environmental benefits from reduced patient travel, which we have not considered. Therefore, the monetised benefits likely represent a lower bound estimate of the overall benefits associated with telemedicine.

Existing Technical, Socio-Economic and Regulatory Barriers Complicate the Adoption of Telemedicine in Canada

Telemedicine has seen a significant increase in use since the beginning of the COVID-19 pandemic, mainly because it rapidly became a central means of providing healthcare to patients whilst containing the virus. Yet, despite governments temporarily lifting some barriers to allow the broader use of telemedicine, the COVID-19 outbreak has emphasised the presence of many remaining barriers that have hindered a wider uptake before the pandemic. Addressing the third research question, we conducted a targeted review of the literature to better understand the existing barriers. Some of the barriers identified in the literature are universal, while others are specific to Canada. The three main types of barriers identified are: (1) technical barriers; (2) socio-economic barriers; and (3) regulatory barriers.

Technical Barriers: Technical Standards, User-Friendly Solutions and Skills Training

The existing Canadian infrastructure that would be required for telemedicine applications (such as access to fixed and wireless broadband) is relatively well developed, and suits most current telemedicine applications. For instance, in Canada, 99.5 per cent of households have access to 4G LTE, with average download and upload speeds of 60 Mbps and 10.5 Mbps, respectively; 98 per cent have access to fixed broadband services with at least 5 Mbps download speeds; and more than 92 per cent have access to broadband speeds of at least 50 Mbps or more. To put these figures into perspective, it is recommended that a minimum download speed of 5 Mbps is used to stream high-definition video, or 25 Mbps for ultra-high-definition video.

While the availability of access to broadband (fixed and wireless) required for many telemedicine applications is virtually universal, there is a lack of integration, standardisation and interoperability of the technical infrastructure related to telemedicine. This is manifested in a lack of standardisation of the procedures, terminology, equipment requirements, Information and Communication Technology (ICT) infrastructure, health provider identifiers, service identifiers and data transfer requirements across different regional jurisdictions. For instance, instead of a harmonised and standardised patient health record, there exists a myriad of separate systems for primary care and hospital records, laboratory results and prescription documentation, and systems cannot connect well with each other.

The shift to telemedicine could also be hindered by a lack of user-friendly solutions (one major issue for technological acceptance of telemedicine systems is the lack of support for users). Without ease of use or general support, problems during the use of the technology can lead to de-motivation and a high probability of abandoning the technology.

In addition, a lack of adequate skills and training among healthcare staff could adversely impact the development and use of telemedicine applications. For instance, if healthcare professionals struggle to use the technology because they lack the adequate skills, technology advancements may not be adopted in the first place or not be efficiently used to promote the best quality of care for patients.

Socio-Economic Barriers: Health Inequities and Digital Literacy

In Canada significant health inequities are observed among indigenous peoples, racial minorities, immigrants, people living with functional limitations and a gradient of health inequalities by socio-economic status (e.g. by income, education levels, employment and occupation status).

Yet, it appears that these patients who stand to benefit the most from telemedicine are also often those who are least likely to be able to access and make use of it. For instance, for low-income individuals or households, the cost of buying suitable equipment to engage in telemedicine could be prohibitive. Age has also been recognised as having a significant influence on the ability to use telemedicine, since older, less mobile people may be less comfortable with using new technologies compared to younger people. Other factors such as ethnicity, culture, language or religion can also have an impact on people's willingness to use telemedicine services, particularly if these aspects have not been taken into account during the development stage of the system. There is also the challenge of lack of digital health literacy among certain populations in Canada. Individuals with lower levels of digital literacy tend to come disproportionally from population groups with lower socio-economic status or education levels, ethnic minorities and older adults, putting them at greatest risk of exclusion from technological advancements. For instance, in Canada, adult competency scores assessed by the Organisation for Economic Co-operation and Development (OECD) suggest that skills associated with digital literacy—such as numeracy and problem-solving skills in technology-rich environments—are lower in areas with higher percentages of indigenous or immigrant populations.

Regulatory Barriers: Licensing, Compensation and Access to Patient Information

Legal gaps and discrepancies across provinces in terms of licensing obstruct the development of telemedicine services. In Canada, the organisation and regulation of health services by care providers, and the supervision of the activities of health professionals, fall mainly under provincial jurisdiction. As such, healthcare professionals may need to go through various regulatory authorities to understand the applicable rules and, in some cases, to obtain permits or authorisations to practice in other provinces. Thus, in most cases a physician needs to be licensed in every province where they provide traditional medical care. The only group that is exempt from this requirement are physicians serving in the Canadian military.

Another regulatory obstacle to the wider use of telemedicine is the lack of clear reimbursement mechanisms for telemedicine procedures, both regarding the payment model used and the provincial implications deriving from it. Before the COVID-19 pandemic, according to several provincial and territorial billing rules, the physician must either personally carry out or have direct supervision over any procedure for it to be billable and compensated, and therefore payment systems predominantly encourage face-to-face consultations. There is, however, some regional heterogeneity in terms of reimbursement of remote consultations, as some provinces—such as British Columbia, Alberta, Ontario and Prince Edward Island—have established telemedicine fee codes for services between physicians and patients. The regional heterogeneity in reimbursement mechanisms for remote consultations has been noted as a barrier in the uptake of telemedicine more broadly, due to uncertainty about reimbursement mechanisms if certain telemedicine services are provided in other municipalities.

Furthermore, to improve the uptake of telemedicine, or to sustain the levels experienced during the COVID-19 pandemic, certain interoperability standards are necessary so that practitioners (and patients) can have seamless access to electronic health record data. This indirectly relates to the licensing barrier that exists in federated countries and regions such as Canada, where restrictions on the provision of care across provincial/territorial boundaries exist and where initiatives to facilitate cross-jurisdictional licensure should thus be undertaken. At the same time, there are potential issues with privacy of personal health information for patients, providers and insurance companies, which could adversely affect patients’ and clinicians’ level of trust and willingness to adopt and use telemedicine systems.

Seven Recommendations to Address Existing Technical, Socio-Economic and Regulatory Barriers

While some technical, regulatory and socio-economic barriers in Canada have been temporarily removed in the wake of the COVID-19 pandemic, to obtain the benefits of telemedicine in the longer term some of these barriers would have to be removed permanently. To address the fourth research question, we have reviewed existing academic and public policy reports. Table 4 highlights seven specific recommendations on how the identified technical, socio-economic and regulatory barriers could be addressed.

Table 4.

Summary of Seven Recommendations to Address Some of the Existing Technical, Socio-Economic and Regulatory Barriers

Type of barrier	Recommendation
Technical	1	Ensure technical interoperability of electronic health records
	2	Develop user-friendly solutions for telemedicine platforms
	3	Provide relevant education and training to health care staff
Socio-economic	4	Address existing health inequities and improve digital health literacy
Regulatory	5	Develop a national strategy to address jurisdictional licensing barriers for physicians
	6	Modify the existing fee code system to address physician reimbursement issues
	7	Develop national standards for patient health information access

Technical Barriers

Recommendation 1: Ensure technical interoperability of electronic health records.

To ensure an efficient and timely use of electronic patient data, Canada should update the existing fragmented system of electronic health records. To increase the interoperability of health information, experts have called for an establishment of a nationally harmonised patient record system, which could be achieved through mandating and improving a current health record system (e.g. with inputs from practitioners and patients) that would then be used across Canada. The European Commission has adopted a recommendation on a pan-European electronic health record exchange format to unlock the flow of health data across borders and facilitate cross- border interoperability of electronic health records.

Recommendation 2: Develop user-friendly solutions.

As Canada moves to increased use of telemedicine, the development of simple tools and platforms accessible to all should continue to be considered by the developer of the technology. These solutions need to be user-friendly, as some evidence suggests that lack of technical and practical support is often a barrier for users of telemedicine applications, for both practitioners and patients. Moreover, developers of telemedicine technologies should make them compatible and easy to use for all individuals, independent of their age, language, ethnicity or income, which could help to address some of the identified socio-economic barriers to telemedicine uptake.

Recommendation 3: Provide relevant education and training to healthcare practitioners.

Adequate skills and training among healthcare staff are necessary to develop telemedicine. The inclusion of formalised telemedicine education and training in medical schools is key. An early introduction to telemedicine equips medical trainees with core competencies in digital patient care, clinical knowledge and practice-based learning, and also fosters their sense of familiarity with telemedicine, preparing for a practice with increasing usage of telemedicine applications. While countries like the United States or Germany already have a more advanced telemedicine curriculum in undergraduate and postgraduate medical education curriculum, Canada lacks a well-formalised telemedicine content in medical school curricula.

Socio-Economic Barriers

Recommendation 4: Continue to address existing health inequities and improve digital health literacy.

To keep up with advancements in technology, the digital divide across different population groups needs to be addressed. Further improvements in digital skills are vital, especially in programs that can address the skills gap among certain populations (e.g. indigenous populations, older and lower income households). Moreover, there is a need for removing financial barriers for lower income households by, for example, implementing co-payments for teleconsultations or waivers to purchase needed equipment, such as smartphones (as well as data plans or internet access).

Regulatory Barriers

Recommendation 5: Develop a strategy to address jurisdictional licensing barriers.

Like existing efforts in the European Union or the United States, Canada needs a more harmonised telemedicine strategy to address jurisdictional barriers and to simplify the registration and licensure processes for qualified physicians to provide virtual care across provincial and territorial boundaries. This could involve fast-tracking licensing and license portability for physicians to harmonise licensing, potentially by providing support to the Federation of Medical Regulatory Authorities of Canada and by writing cross-jurisdictional guidelines for telemedicine.

Recommendation 6: Modify the existing fee code system to solve reimbursement challenges.

Modifying the existing fee code system will allow for the permanent delivery of telemedicine, thus ensuring that the delivery of all telemedicine services is eligible for compensation. Incentivising the uptake of telemedicine in Canada could involve directing resources and savings towards providing equivalent compensation for physicians for remote services, as for in-person service delivery. This would allow all modalities of telemedicine to be billable through the development of fee schedules that are revenue-neutral between in-person and remote encounters.

Recommendation 7: Develop national standards for patient health information access.

The further development of national standards for patient health information access in Canada is crucial for effective care coordination among the different healthcare stakeholders. Ensuring that electronic data follows patients across delivery settings is one way to address a key barrier to effective care coordination. Among developed countries, existing standards emphasise either a single patient-data repository—as is the case in Australia – or sharing of data from point to point, as is the case in Denmark and the United States. National standards should protect privacy, security and confidentiality of patient data.