Toronto hospitals have a successful virtual ER program. But its time is running out

The virtual emergency department set up by some of Toronto’s biggest hospitals has been a success.

More than 3,000 patients in the past two to three years have avoided an unnecessary trip to a bricks-and-mortar emergency department by using the service, a partnership between the University Health Network, Sunnybrook and Unity Health.

But the virtual department may be in its last days. Provincial funding, which has been temporary, runs out at the end of March.

If that happens, the virtual service won’t be sustainable.

“We’re trying our best to maintain it and support it internally,” said Dr. Sameer Masood, an emergency physician and director of emergency department quality, safety and innovation at UHN. “But in the end, it’s not something we can do indefinitely. So if there’s no plan or vision from the ministry, it may have to ramp down.”

Another alternative, said Masood, may be a privatization model similar to Rocket Doctor and Maple. Both are online medical platforms that charge patients for appointments with doctors by chat, a service not covered by OHIP.

“I hate to sort of make this a privatization topic,” said Masood, “but I would not be surprised.”

But he stressed there is no plan to charge patients.

Ontario’s Health Ministry didn’t respond to repeated requests asking if it would extend the funding.

Virtual care was rare before the pandemic.

Then COVID-19 swept in extraordinary changes to the health-care system, including a huge jump in online medical appointments, and the government allowed family doctors to use the same billing codes for OHIP as they would if they saw a patient in person. A typical charge per in-person appointment is $36, according to the Ontario Medical Association.

However in December, when a new physician services agreement negotiated between the OMA and the province took effect, the fees for virtual-only medical appointments with family doctors were reduced to $20 for video and $15 for phone.

In the wake of the fee change, numerous online-only medical providers went private, billing patients for appointments by using chat, or out-of-province doctors, services not covered by OHIP.

But that wasn’t the case for virtual-only emergency departments that were set up using an envelope of temporary government funding. In those cases, doctors have been allowed to bill for the virtual-only appointments on par with what they would had they seen the patient in person.

It’s a contradiction within government funding, with the province devaluing virtual-only medicine by family doctors, but not virtual-only care in hospital emergency departments.

The province has said in the past that it wants to encourage wraparound, ongoing care by family doctors; seeing patients in person, as well as virtually, is an important component of that.

But virtual-only emergency departments have proven to be fairly successful, by all accounts.

“We know that half the patients that come to the emergency department have lower-acuity complaints,” said Masood. “And 80 to 90 per cent of those patients are going to be discharged home, many of them with no specific intervention. And many of them don’t need to be seen in person.”

The service is available to patients in Ontario with an urgent medical problem that is not life-threatening. Appointments are available Monday to Friday from 9 a.m. to 9 p.m., and on the weekend from 9 a.m. to 1 p.m. Booking opens daily at 7 a.m. for same-day appointments.

The hospital’s virtual emergency department sees patients from other cities in Ontario who connect because they don’t have the same opportunity in their local community, said Masood.

“They should not have to connect with UHN if they’re living in London or Peterborough or Oshawa,” he said. “They should be able to connect with their own local unit.”

Masood said if provincial funding isn’t extended, and family doctors who work in the virtual emergency department have to bill OHIP $20 for a video appointment in line with the latest physician services agreement, it wouldn’t be enough to make ends meet.

“You’re essentially underpaying physicians to the point where it doesn’t make sense for anyone to engage in this,” said Masood. “Which is why a lot of companies, a lot of family physicians have essentially ramped it down and stop doing it. And now patients have to go and see someone in person, book an appointment, wait for weeks just to get a prescription renewed or follow up on a previous visit, for example,” he said.

Not every hospital has a virtual emergency department. And some don’t use a model like UHN’s, which is run internally.

Last summer, Georgian Bay General Hospital began a pilot with the technology platform Rocket Doctor, whose website connects doctors in Ontario to patients virtually for non-emergency needs.

Matthew Lawson, president and CEO of the hospital, said the virtual service is an alternative for patients who might otherwise have to visit the emergency department because they don’t have a family doctor, which he said is true for many residents of the area.

Rocket Doctor was founded during the pandemic by Dr. William Cherniak, when OHIP covered the fees paid for virtual appointments with family physicians at the same rate as in-person appointments. When OHIP fees for virtual-only appointments were reduced in December, Rocket Doctor began charging $55 for chat appointments, which aren’t covered by OHIP.

But the company continued to offer OHIP-covered appointments at the reduced rate for the Georgian Bay hospital.

“We are disappointed with the change” in the services agreement, said Lawson, “but we recognize that there are limited funds.”

Cherniak said in an interview that Rocket Doctor has seen about 1,000 patients through the Georgian Bay hospital.

Brant Community Healthcare System, which includes Brantford General Hospital, has also partnered with Rocket Doctor to provide an alternative to the emergency department for patients in the area, many of whom have no family doctor.

“It gives us just one more option to redirect our patients to,” said Dr. Somaiah Ahmed, the system’s chief and medical director of emergency medicine. The partnership also began before the OHIP fees for virtual-only medicine were reduced but Rocket Doctor has continued to provide the insured service to patients despite the lower fees.

Lawson believes there’s a place for virtual medicine in the province’s health-care system because of the shortage of family doctors as well as a shortage of other medical professionals.

“Obviously, if an individual can get into the family doctor, that’s where they should be going,” said Lawson. “But in the absence of that, I think a model like this is positive for reducing the burden on the emergency department and for allowing Ontarians timely access to health care.”

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