Abstract

The COVID-19 pandemic has necessitated a rapid change in the delivery of healthcare around the world. Many facilities have transitioned suitable services to virtual care to reduce the risk of viral transmission and preserve healthcare resources for spikes in COVID-19 cases. Since institutions have rapidly expanded the usage of virtual care beyond its previous confines, investigations are required to ensure that the adapted system is working for patients. While important, clinical and patient-reported outcome data do not provide complete insight into the specific impacts of pandemic-time changes from the patient’s perspective. Therefore, to get a complete picture of these changes, it is also necessary to look at patient experience, which evidence suggests, could be impacted by virtual care in positive ways, but only in specific cases. Thus, it is vital to record pandemic-time patient experiences and analyse how the implementation of virtual visits impacts the delivery of person-centred care. This data should be used to determine how virtual care can be optimally implemented into the Canadian healthcare system after the resolution of the COVID-19 pandemic. Although it is currently unclear how virtual care will be integrated into the post-pandemic landscape, the approach offers benefits to both patients and providers. Canada-wide, longitudinal studies investigating patient experience using virtual care during the COVID-19 pandemic are required in order to ascertain exactly how this novel approach can be leveraged to benefit patients.

The Reporting of Patient Experience Data in Canada

Person-centred care is a healthcare ideology wherein clinical decisions are based on patients’ personal preferences [1]. Person-centred care is reliant on the integration of clinical data, patient-reported outcome measures (PROMs), and patient-reported experience measures (PREMs) [1]. PREMs record patient experience, which is defined as a patient’s perception of their delivery of healthcare [2]. Patient experience encompasses the complete range of interactions between patient and provider and illustrates the granular elements of a patient’s healthcare experience [2].

In 2015, the Canadian Institute for Healthcare Information (CIHI) developed the first and only pan-Canadian system for reporting patient experience data, called the Canadian Patient Experiences Reporting System (CPERS) [3]. Participating acute care facilities across Canada use CIHI’s Canadian Patient Experiences Survey on Inpatient Care (CPES-IC) to collect data regarding patient experience throughout a patient’s particular hospital admission. This standardized survey is endorsed by Accreditation Canada and consists of 49 questions, including 22 questions from the Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which is used in the United States [3]. The Canadian survey evaluates many different aspects of patient experience, such as communication with doctors, discharge management, overall hospital experience and demographic information [3]. After submitting the surveys to CIHI for centralized analysis, healthcare providers and other stakeholders can access CPERS to compare their results to other hospitals, view trends in the data and work towards improving patient experience.

The Value of PREMs

While some studies have noted drawbacks associated with using PREMs to structure satisfaction-based reimbursement for healthcare systems like the renumeration set-up in the United States [4,5] these deficiencies do not delegitimize the recording of patient experience, especially in jurisdictions like Canada that do not have consumer-driven healthcare systems. The recording of patient experience data is a vital component in modern healthcare, as it allows for the provision of person-centred care and gives patients a way to have their concerns addressed. Improving patient experience is recognized as part of the Institute for Healthcare Improvement’s “Triple Aim” framework for improved healthcare alongside improving the health of populations and reducing the per capita cost of healthcare [6]. Additionally, an influential systematic review of studies from around the world has demonstrated that improved patient experience is correlated with improved patient safety, improved clinical effectiveness and improved patient-reported and clinical outcomes [7]. While none are individually sufficient measures of healthcare delivery, PREMs, PROMs and clinical outcomes are all invaluable indicators of progress towards strong, person-centred healthcare systems. As healthcare systems evolve as a result of the strain placed on them by the COVID-19 pandemic, these indicators become increasingly significant in the effort to preserve the person-centred focus of the Canadian healthcare system.

Virtual Care in Canada

With the 2020 onset of Canada’s COVID-19 pandemic, many healthcare providers across the country have been forced to transition to “virtual care,” a term that designates any interaction between patient and healthcare team that occurs remotely and uses a form of communication technology [8]. While each province and territory has been affected by the pandemic differently, jurisdictions across Canada have been encouraged and supported by their respective provincial guidelines to make this transition9. Ultimately, this has reduced the number of face-to-face appointments and increased the use of virtual care in Canadian primary care since the onset of the pandemic [10,11]. 

There is currently a paucity of studies investigating how patient experience has been affected by the rapid expansion of virtual care since the onset of the pandemic. One promising study from before the pandemic used PREMs to study the Ontario Telemedicine Network and uncovered a wide variety of striking effects [12]. After virtual appointments, patients in the study received an online survey, the results of which ultimately demonstrated that virtual care could have a positive impact on patient experience, but only when implemented appropriately. Researchers found that virtual care can eliminate the hassle, time and cost required to commute to appointments and can provide access to specialized care otherwise unavailable in remote regions. However, virtual visits also require that patients have smart devices, good internet connections and proficient technology skills, which can pose challenges for some patient groups [12]. Additionally, with virtual care, providers are unable to conduct a physical examination, and non-verbal cues can be difficult to interpret [12]. The researchers concluded that appropriate cases for virtual care include routine check-ins, chronic disease management and follow up appointments, and exclude cases that require a physical exam, the prescription of narcotics or the delivery of bad news.

Ultimately, this study conducted prior to the COVID-19 pandemic demonstrates the positive effects that virtual care can have on patient satisfaction when it is implemented gradually, methodically and in specific cases. However, the COVID-19 pandemic has mandated the rapid and almost ubiquitous implementation of virtual care, and the effects of these changes on patient experience have yet to be analysed in long-term Canada-wide studies. Without such studies, it is difficult to ensure the continued provision of person-centred care during the pandemic and following its conclusion.

To date, there has only been one study investigating the effects of the Canadian pandemic-time transition to virtual care on patient experience. This study was conducted by the University of Toronto (U of T) Department of Family and Community Medicine across 14 different family medicine teaching clinics [13]. From June to September 2020, PREMs were provided to 7532 patients who had received primary care from a physician affiliated with U of T. This PREM assessed the appointment booking process, quality of care provided, experience accessing urgent care, and additionally recorded patients’ future recommendations. The results of this survey indicated that patients want to continue utilizing virtual care, feel comfortable with the level of privacy provided, could obtain an appointment within a reasonable amount of time, and felt involved in their healthcare decisions— indicating the provision of person-centred care [13]. However, this investigation highlighted worse experiences using virtual care amongst those of low socioeconomic status, immigrants, and people with serve health issues. This study has yet to be peer reviewed or published, but the results of this study, and the PREM that was used are available on the U of T website. This initiative provides limited but promising insight into the pandemic-time patient experience using virtual care and can help stakeholders direct future, necessary assessments of the virtual care landscape in Canadian healthcare. 

Moving forward, providers should consider their patients’ preferences, along with public health guidance, when deciding between virtual and in-person appointments. Virtual care can benefit patients in many ways, but they should be consulted with respect to their appointment modality to ensure the provision of person-centred care. Providers should consider the use of post-virtual appointment PREMs to assess the patient experience of virtual appointments and work towards improving patient experience.

The Need for Improved Patient Experience Reporting

Although the broad effects of virtual care on the patient experience have not yet been thoroughly analysed, it is clear the changes made to the Canadian healthcare system as a result of the COVID-19 pandemic have exposed flaws in the current system for recording patient experience data. Currently, CIHI’s CPERS is the only pan-Canadian patient experience database and reporting platform, and it only collects patient experience data regarding a patient’s single hospital admission. CPERS does not collect patient experience data from patients across multiple hospital admissions, from the integrated use of multiple components of the healthcare system or, most notably, from virtual visits [3]. 

As such, there is a strong need to develop and evaluate a PREM that takes into account pandemic-time changes, such as the implementation of virtual care, and considers the complete range of a patient’s touchpoints with the healthcare system. This PREM must be suitable for systematic and longitudinal use, both during the pandemic and after it, and it must be integrated into the pan-Canadian reporting system so that jurisdictions can learn from each other and improve. This is especially important at a time when the Canadian healthcare system has been changed more substantially and rapidly than ever before. Without effective, accurate, and large-scale tools for analysing patient experience in Canada’s new virtual care landscape, providers risk sacrificing the compassionate values that drive person-centred healthcare systems across the country.

Conclusion

The Canadian healthcare system’s response to the COVID-19 pandemic has included measures to protect patients and healthcare workers by implementing a transition to virtual care whenever possible. However, the effects of these changes on patient experience have not been analysed. The pandemic in Canada is far from over and will likely result in lasting change in the landscape of Canadian healthcare, even including a lasting transition to virtual care. This transition to virtual care need not be entirely negative – in fact, it is possible that the widespread implementation of virtual care is long overdue in a slow-adapting system plagued by inertia and bureaucracy. Nevertheless, the effects of virtual visits on PREMs and patient experience are not particularly well known and should be studied, particularly to help ascertain whether virtual visits should be offered more frequently once in-person visits can resume more safely.

Acknowledgements

Funding Statements

This study was generously supported by the Queen’s University Bartlett Student Initiatives Fund.

Declaration of Competing Interests

The authors have no competing interests to declare.

Author Information

Authors and Affiliations

Queens University, Kingston, ON, Canada

Jacob I. Wise

Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada

Lusine Abrahamyan

Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre (PMCC), University Health Network, Toronto, ON, Canada

Lusine Abrahamyan, Ada C. Stefanescu Schmidt, Eric Horlick

Corresponding Author

Please direct correspondence to Jacob I. Wise.

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