Healthcare access, specifically to specialist care, has remained a persistent challenge for rural communities worldwide. Countries like Canada and the United States experience significant disparities in the number of physicians and specialists per 100,000 residents compared to their urban counterparts. The resulting impact? Rural patients tend to experience higher rates of chronic diseases, preventable hospitalizations, and mortality rates. Virtual Hallway (VH) is a unique platform that uses technology to bridge the rural-urban healthcare divide.
While the struggle to provide patient care in rural areas is not new, it's fraught with an array of challenges. Patients often face a difficult choice between long waits for appointments at distant clinics or forgoing specialty care altogether. With internal medicine, surgical specialty services, and mental health services witnessing unpredictable coverage gaps, this lack of system redundancy in rural healthcare only amplifies the issue. These scenarios inevitably lead to an increase in complex and often costly patient transfers.
However, the solution to these challenges may lie in digital tools like Virtual Hallway. Designed to facilitate phone consultations between primary care providers and specialists, VH's aim is to dismantle geographical barriers in healthcare provision.
VH's impact is not just theoretical. Real-world data from VH users reveal an astounding 84% of phone consultations successfully avoided the need for an in-person referral. Think of it: near-instant access to a specialist, right within your rural community. This effectively eliminates long waits and reduces the need for lengthy travel to urban centres.
Recent user surveys indicate that around 95% of primary care respondents either "strongly agreed" or "agreed" that VH increases access to specialist consultation. In fact, 98% affirmed that VH enhances their capacity to manage care plans in their communities. Additionally, VH garnered high satisfaction rates, with 99.4% of users reporting they were "very satisfied" or "satisfied".
The introduction of VH offers hope in the quest to level the healthcare playing field between rural and urban communities. To uncover more about the potential of VH and its impact on rural healthcare, dive into our comprehensive white paper "Bridging the Rural-Urban Divide". Find out how VH is changing healthcare, one call at a time.
We at Virtual Hallway are excited to announce our collaboration with the Nova Scotia Mental Health and Addictions Program (MHAP) and the Nova Scotia Health Innovation Hub. Our collaboration aims to improve access to mental health care in Nova Scotia, where the system is overburdened and many people struggle to receive the care they need.
Virtual Hallway was founded by three Nova Scotian psychiatrists and improving access to mental health care is the core part of our mission. We believe that everyone should have access to high-quality mental health care, regardless of what part of the province they live in. Our collaboration with the Nova Scotia Mental Health and Addictions Program and the Nova Scotia Health Innovation Hub is an important step towards achieving that goal.
Our platform allows primary care practitioners to connect with psychiatrists in real-time. The platform is accessible to all Nova Scotian primary care practitioners, making it easier for people to receive the care they need, when they need it.
Access to mental health care is a critical issue in Nova Scotia, and our collaboration with the MHAP and the NSH Innovation Hub has the potential to transform the way mental health care is delivered in the province.
Our healthcare system is faced with a number of challenges, from overcrowded emergency departments to long wait times for specialist care. In order to improve access to care and reduce overuse of emergency departments, many healthcare providers are turning to a solutions that can make specialist consultation more effective. These innovative technologies offers a range of benefits, from connecting primary care providers with specialists in real-time to bringing specialist insights to patients. In this article, we'll explore how synchronous phone consultations can help reduce overuse of emergency departments and improve access to care.
Emergency departments are often overcrowded and overburdened, leading to long wait times and delayed care for patients who need it most. One solution to this problem is the use of synchronous phone consultations, which can help reduce overuse of emergency departments by improving access to primary care providers and specialists.
Emergency departments are overcrowded, leading to long wait times and delayed care for patients who need it most. Patients stuck on specialist waitlists are ER admissions in the making. The longer a person waits, the more likely they are to require urgent or emergent care. High frequency ER patients are often a result of inability to manage complex comorbidities. With growing specialist waitlists, the percentage of patients going untreated increases, and as a result so will potentially avoidable admissions. Are increasing ER admissions in part caused by increasing waitlists?
Synchronous provider-to-provider phone consultations can reduce overuse of emergency departments by improving access to specialists. In traditional healthcare systems, primary care providers often have to refer patients to specialists for further evaluation and treatment. However, this process can be slow and cumbersome, and patients may have to wait months or even years to see a specialist. This wait time can lead to patients showing up in the emergency department with complex, chronic conditions that could have been managed earlier with specialist input.
Synchronous phone consultations offer a number of benefits. By allowing primary care providers and specialists to have a synchronous dialogue, it helps ensure that all parties are on the same page when discussing patient care. This can lead to better collaboration and more effective treatment plans, which can reduce the need for emergency department visits. Direct collaborative communication between providers can take efficiency to the next level. By exchanging information directly, doctors can avoid the time-consuming process of reviewing patient files, scheduling appointments, and waiting for specialist feedback. This direct communication not only saves time but also increases the likelihood of the advice being actioned.
Asynchronous solutions like e-consults can also be part of the solution. E-consults allow primary care providers to send a secure message to a specialist, who can then review the patient's case and provide recommendations. This can help reduce the need for in-person specialist referrals, which can be unnecessary and time-consuming. This is particularly important for patients who are stuck on waitlists and may not be able to see a specialist in person for months.
Let's consider the case of a patient with borderline personality disorder and a substance use disorder, who had longstanding difficulty stabilizing their condition. This patient was previously a frequent visitor to the emergency department of a regional hospital in a rural area, staffed mainly by family doctors. Unfortunately, there were no psychiatrists in the area, and even though this patient had a family doctor, they were unable to get the patient to be seen by a psychiatrist in the closest urban centre (a 4-hour drive away).
Without psychiatric advice and support, the family doctor was limited in their ability to help the patient manage their conditions effectively. The result was that this patient frequently visited the emergency department for symptoms related to their mental health and substance use disorders.
However, after implementing phone consultations between primary care providers and psychiatrists, the family doctor was able to collaborate with specialists in real-time to develop more effective treatment plans for this particular patient. With ongoing support from these specialists via synchronous phone consultations, the family doctor was able to better manage this complex case.
As a result of these consults, this patient is no longer frequenting the emergency department unnecessarily. Thanks to improved access to expert advice and collaborative communication between providers involved in their care through these efficient consults, this patient is now receiving adequate care without having to travel long distances or wait months for specialist appointments. This demonstrates how powerful synchronous phone consultations can be in improving access to care and reducing overuse of emergency departments for patients with complex comorbidities living in rural areas where specialist resources may be scarce.
Phone consultations are a promising solution to the challenges facing our healthcare system today. By connecting primary care providers with specialists in real-time, phone consultations can help address issues before complications arise, reducing the need for emergency department visits. Additionally, asynchronous solutions like e-consults can also be part of the solution by reducing the need for in-person specialist referrals. Overall, phone consultations are powerful tools for improving access to care and reducing overuse of emergency departments. By reducing the number of potentially avoidable admissions, we can help alleviate the burden on emergency departments and improve patient outcomes.
For Family Doctors and Nurse Practitioners in Ontario who need access to specialists, asynchronous eConsults and synchronous phone-based Virtual Hallway are both secure and free-to-use solutions.
Most importantly, each tool helps primary care providers keep patients off the wait list and deliver better, faster and often life-saving outcomes to patients.
When considering which tool to best suited for each case, it's helpful to consider the ways in which they are unique. This will help primary care providers determine which one might be the best fit for their working preferences and patient needs.
E-consultations are a long-standing and widely adopted solution that recreates some aspects of a live, hallway-style consultation. The asynchronous nature of emails is helpful in many contexts and many clinics and hospitals have integrated it into their standard workflows.
Benefits of email-based consultation through eConsult include:
Did you know: in Ontario, 40% of eConsults avoided an unnecessary referral and 60% do not require an in-person followup visit. Source.
Discussing a patient’s case with a colleague in a clinic or hospital hallway is the original gold-standard in patient-specific medical consultation and knowledge sharing. Phone-based consultations allow primary care providers to experience the benefits of a “hallway”-style conversation outside the confines of their immediate network, clinic or hospital.
Virtual Hallway brings ease and convenience to this approach with technology aligned to CMPA guidelines, modern clinic workflow and billing criteria.
Benefits of phone-based consultations through Virtual Hallway include:
Did you know: in Nova Scotia, 84% of phone consultation through Virtual Hallway helped a patient avoid a specialist waitlist entirely. Source.
Email and phone-based consultations are both important tools that help primary care providers provide better, faster often life-saving patient care. Consider your patient case and personal preferences when determining which tool is the best fit:
Meet Liz, 24. She has a hard time focusing at work.
Liz visited her family doctor for this reason. While assessing Liz, they found she had a fast heartbeat and an abnormal ECG, causing hesitancy about prescribing ADHD medication to improve her attention. With Liz's best interest in mind, she was referred to an internist for an in-person appointment.
3 months passed; Liz heard nothing. Still having trouble focusing, she called her family doctor's office for an update. She was told that the referral was sent and to keep waiting.
Another 3 months passed; Liz’s troubles continued. Her performance at work was suffering and her trouble focusing was interpreted by her manager as lack of interest in her role. Liz had several write-ups due to lack of productivity and missed deadlines.
Liz was frustrated and concerned; but kept waiting.
3 more months; Liz visited an internist. The internist interpreted the ECG and created a treatment plan that allowed Liz to best manage her condition and improve her performance at work.
Liz was still frustrated; it took 9 months of waiting to get the treatment she needed. She asked herself ‘isn't there a better way?’
Long story, short solution - a Virtual Hallway consult.
Virtual Hallway phone consults are available within 1-2 days, enabling specialist input earlier on in the course of a patient’s illness. The platform facilitates knowledge sharing between specialists and primary care providers, in turn, motivating more timely and effective care.
A Virtual Hallway consult in the case of Liz?
9 months of waiting, worsening and wondering – avoided.
Professional knowledge and confidence – shared.
Specialist waitlist – one patient shorter.
A Family Physician returned to the Maritimes to set up a practice in the remote community in which she grew up. While she worked in Toronto, she longed for the Nova Scotia’s beautiful vistas and the strong sense of community. When the community’s family doctor retired, she knew this was her chance to go home.
The differences of rural practice.
After working in Toronto, the transition to practicing in a small community, away from the big hospitals posed challenges. She was no longer able to easily send people to the emergency room and patients were reluctant to drive 4-5 hours to go to see a specialist or get a diagnostic test. She also had few connections in the medical community. She felt clinically isolated.
Her patients had complex conditions, and she worried that they were being sub-optimally treated. She tried to make referrals for her patients who needed to see a specialist, but the waitlists were long, and patients preferred to get treatment with her, rather than driving into the city.
Plugging into a clinical network
She had joined a physicians Facebook group and heard of the clinical network of physicians doing phone consults through Virtual Hallway. She checked out the website but didn’t sign up initially, as she wondered whether it would be another piece of software she would have to learn to use.
Later, she heard about an online lecture about Frailty being held on Virtual Hallway led by Dr. Ken Rockwood and decided to watch. After listening to the lecture, she decided to set up for an account. And then, within minutes, she sent her first consult request, a consult with an Internal Medicine specialist. “I couldn’t believe how simple it was, just a few clicks and I had a booking to talk to a specialist.” The patient had been on a waitlist for eighteen weeks, and the patient’s kidney function was gradually deteriorating.
The next day, the Internist called, on time. “It was great. He was so easy to consult with. We worked through the case, and we came up with several steps that I was able to implement immediately.” Within a few weeks the patient’s creatinine was coming back up, and her blood sugar control was improving.
Building relationships.
After that first consult, she made a couple more requests, and then a few more. Now, she sends an average of three consult requests per week. Her most frequently consulted specialties are Internal Medicine, Psychiatry and Gastroenterology. Her patients are now able to get specialty level input within days, while staying in their community.
While she prefers completing and booking consults herself, she has her administrative staff download the documentation and import it into her electronic medical record. The extra income was a bonus.
“The best part has been getting to know my colleagues.” She has now built relationships with a few specialists, and the conversations have been concise and collegial.
In addition, she has found that consulting with a specialist earlier on in the patient’s course has led to fewer complications and improved outcomes. And ultimately, fewer patients have needed to go onto a specialist’s waitlist and have received care sooner.
Incentivizing Mental Health Providers to Offer Travelling Services
I hung up my phone after a long call with a clinic manager in a rural Nova Scotia community. She called to ask if I knew of any psychiatrists who would be available to work in her community one day a week. She pleaded, “We are desperate to find someone who can help. Our young people are suffering. There must be someone who wants to see the beach.”
Unfortunately, I did not know a physician who would be willing to drive 500 kilometers to see a patient...and the ocean waves, as magnificent as they are.
Rising Wait Lists in Rural Communities
Rural and remote communities in Canada face unique challenges in providing access to quality mental health services...Where services do exist, they are frequently stretched thin, with long wait lists, high turnover rates, and poor communications infrastructures. [1]
When services are not available in a community, people are often left with no choice but to travel long distances to get help they need. Even then, people are not guaranteed an appointment.
Wait times to see a psychiatrist in Halifax, the province’s capital city, can range from five to eight months. By the time a patient gets seen, their conditions have often worsened.
Three of Virtual Hallway’s founders - also practicing psychiatrists - made it their mission to find a solution.
Connecting Care through Interprofessional Phone Consultation
The Mental Health Commissioner of Canada suggests the following best practices:
Virtual Hallway incorporates all three through a platform where primary care providers can book rapid phone consultations with specialists to get answers for their patients.
This process eliminates waiting, saves time, and is impartial to distance.
Not all health concerns can be addressed by a phone call, but more than 35% of referrals [2] are appropriate for an interprofessional phone consultation. For patients with more complex cases who do require a face-to-face visit, Virtual Hallway is a resource to support their ongoing care while they wait to be seen.
Increasing Access
Even though I could not recommend one psychiatrist who would be willing to travel such lengthy distances for work, I could offer the practitioners in the rural clinic access to four psychiatrists through Virtual Hallway.
Our hope is that specialist input earlier on in a course of illness will streamline a person’s treatment and optimize their care.
This is our mission: to create more efficient and accessible healthcare for everyone.
References
[1] Mental Health Commision of Canada. (2017). Rural and remote mental health in Canada: Evidence brief on best and promising practices. Health Canada. Retrieved from https://www.mentalhealthcommission.ca/sites/default/files/2020-05/Rural_remote_mental_health_evidence_brief_eng.pdf
[2] Keely, E., Liddy, C. (2019). Transforming the specialist referral and consultation process in Canada. CMAJ, 191(15), E408-E409. https://doi.org/10.1503/cmaj.181550
Growing Waitlists in Canada
Long wait times for specialist consultation have been well documented in Canada. The median time from referral by a primary care practitioner to specialist intervention in Canada is 22.6 weeks. The length of the wait time for specialist consultation has increased by 184% between 1993 and 2020.[1]
There is variation between provinces in these numbers. The Atlantic provinces have median wait times that are the highest in the country at over 40 weeks, while Ontario and Quebec cite wait lists that are half the length, at 17.4 and 18.8 weeks respectively.
Within provinces, the wait times can vary across different specialties. In Nova Scotia, a province with some of the longest wait times in the country, government published wait times for outpatient specialty care range from 6 months to over one year.[2]
The Impact of Long Wait Times
Long wait times have serious consequences on individuals and society as a whole. Long waiting times have been shown to be associated with patient dissatisfaction, delayed access to treatments, poorer clinical outcomes, increased costs, and increased mortality. [3] In certain instances wait times can lead potentially reversible illnesses or injuries turning into chronic conditions with permanent disability. In these cases, patients may be unable to work, leading to financial strain and reduced economic productivity.
The Key Role of Primary Care
While patients sit on wait lists, the responsibility for their care falls on primary care practitioners. However, given that the primary care clinician has referred the patient to a specialist suggests that the patient’s needs are out of the primary care clinician’s scope of care. This mismatch between a patient's clinical needs and the immediately available resources is an unfair source of burden on primary care clinicians.
Bringing Specialist Expertise into Primary Care
Over 40% of patients who require specialist input on their care do not require a face-to-face consultation with a specialist but can be addressed through peer-to-peer consultation between the family physician and specialist. [4] These ‘Hallway’ consults have been a longstanding feature of medicine, but with care increasingly being moved from hospitals into disconnected outpatient clinics spread throughout communities, the opportunity for physicians physically crossing paths has become an uncommon event.
Barriers to Interprofessional Communication
Modes of physician-to-physician communication are haphazard. Text messages, emails, faxes, phone calls or messages left at the front desk are routine methods of one physician trying to contact another. However, these unsystematic approaches inevitably lead to missed calls, lost faxes, and messages that are never returned. The result can be a never-ending game of phone tag. Physicians spend hours of time trying to connect with each other, when all that is required is a few minutes.
Technological Innovation
The healthcare Industry has been slow to adopt new technology aimed at improving clinical workflows. Identified reasons for sluggish adoption include multiple stakeholders with competing interests, funding problems, and government regulation. [4] However, in recent years, as technological innovation has evolved and adapted to clinic a workflow while meeting stringent regulatory requirements, adoption of healthcare technology has accelerated.
From Many Steps to One Step
Historically, the referral process involved many steps. The family physician would see the patient and decide that a referral was necessary. They would then complete a generic referral form and most commonly fax it to the specialist. The specialist would review the referral and if it had incomplete information would send it back to the family doctor for revision. If the referral form was acceptable, the appointment would then be booked, typically by arranging a time by phone for the appointment to happen. Each of these steps takes time. Processes with more steps introduce more potential for error. The result is suboptimal care for patients.
Technological innovation now permits these multistep processes to be simplified. No longer do referrals need to be detached from appointment bookings. And no longer do family physicians need to guess what information is relevant to a specialist when making a referral. Process integration allows pulling complex operations into a single step. Using technology to simplify workflows can increase clinician time, and improve efficiency in the referral process. Introducing technological innovation to improve clinic process can allow physicians to more effectively communicate and improve outcomes for patients.
[1] Barua B, Moir M. Waiting your turn, wait times for health care in Canada, 2020 report. Fraser Institute, 2020. Available from:https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2020.pdf
[2] Nova Scotia (2021, August 16). Nova Scotia Health Care Wait Times. https://waittimes.novascotia.ca/procedures/internal-medicine-referrals-interventions
[3] McIntyre D, Chow CK. Waiting Time as an Indicator for Health Services Under Strain: A Narrative Review. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. January 2020.
[4]Herzlinger R. Why Innovation in Health Care Is So Hard. Harvard Business Review, 2006. Why Innovation in Health Care Is So Hard (hbr.org)
