Comment: Poorly handled telemedicine is burdening emergency departments

A commentary by a group of emergency department physicians in Victoria.

There are advantages to telemedicine, also known as virtual care, but there are also concerns.

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Virtual care, which has become commonplace during the COVID-19 pandemic, should be considered an adjunct to, not a replacement for, in-person visits.

Some care can be completely delivered via virtual means and is safe and efficient for patients.

However, it does not always replace the need for a physical exam or an in-person visit with a primary care provider — usually a family physician or walk-in clinic.

In fact, the College of Physicians and Surgeons of B.C. requires that “if a primary care assessment of the patient presentation would normally include a physical examination before referral, the referring physician must ensure that one is done; it is unacceptable to defer a physical examination because the telemedicine medium does not allow for one.”

The comments of doctors Matthew Chow and Vanessa Young, in a March 23 Times Colonist article, accurately reflect the potential advantages of virtual care, but also touch on some of the significant limitations, especially when that virtual care occurs outside of an established doctor-patient relationship ­(episodic care).

Patients sent to the emergency department from digital health companies, who have no pathway available to actually touch their patients, sometimes arrive expecting unnecessary investigations.

Most family doctors on Vancouver Island have adopted an alternative way of delivering care amidst the pandemic.

However, more than a year into this pandemic, with personal protective equipment widely available, people used to being screened before appointments, and almost everyone in the habit of wearing masks when outside their homes, we are still seeing patients every day in our emergency departments who tell us that their primary care provider or walk-in clinic are not offering in-person assessments.

This pattern is concerning to us, as is the statement in the March 23 article about sending patients to the emergency department to facilitate a physical exam.

We see many patients inappropriately show up at our doorstep after being sent in by a primary care provider who has only seen them virtually.

Often patients are sent to the emergency department after a telemedicine consult with minimal or zero attempts by the sending clinician to expedite care (for example, arranging a time to do a physical exam, ordering outpatient imaging or lab tests, or directly calling a specialist for referral).

Emergency department staff members pride themselves on being able to provide the best possible care to everyone who arrives at the door, but our ability to do so has been eroding under the burden of the demand.

Virtual care may be part of the solution to the more general issue of access to medical care, but its current form risks making other issues worse, especially when it occurs outside of a longitudinal relationship with a family physician.

We support a system that combines in-person and virtual visits, but not one where the emergency department is the main option for in-person care.

An emergency department is for emergencies. Primary care, be it virtual, or otherwise, is for primary care.

If you can safely go to a physiotherapist or a dentist, you should be able to physically see a primary care provider.

Our emergency departments continue to experience overcrowding and prolonged wait times, and the explosion of virtual care (especially episodic virtual care) seems to be adding to this burden.

Worse, every day in the emergency department, we see the consequences of incomplete care resulting in delayed, missed or incorrect diagnoses.

Sometimes this risks causing the patient additional harm, but at minimum it is contributing to high patient volumes, packed waiting rooms, and longer wait times for all patients.

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