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Nova Scotia Virtual Care Action Plan

I. Overview of areas of focus

Virtual Care is a care delivery model that seamlessly connects the care team including the patient, regardless of distance, location, or time (Health Care Innovation Working Group, June 2017).  Virtual care represents any interaction whether synchronous (real time) or asynchronous (non real time) between a patient and/or member of their circle of care, without direct contact, using any form of communication or information technology (CHI, 2019). Research shows that virtual care that is well-integrated with traditional models of care can achieve improvements in access, safety, patient experience, population health outcomes and value for money.

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Virtual care that is well-integrated with traditional care can achieve improvements in safety, population health, patient experience, and access, includes:

  • Home Monitoring;
  • Patient Portals;
  • Provider Results Portals;
  • Case Conferencing;
  • eConsult and eReferral;
  • Patient Education;
  • Chat-Book; AI Online Assessment;
  • Online Booking;
  • Virtual Visits;
  • Secure Messaging; and,
  • Remote Clinical Devices.

Principles that Nova Scotia embraces for Virtual Care are:

  1. Enhanced access to care - Virtual care, as part of an integrated model of care, can support access to safe and timely care for patients by enabling a variety of health professionals to provide publicly funded virtual care services.
  2. People and community centred approach - Collaboration and the creation of a shared understanding of delivering and receiving publicly funded virtual health services will support positive outcomes (e.g. patient choice for in-person or virtual, digital equity, digital literacy and etiquette, importance of being prepared for a virtual appointment, and how to support privacy and security).  Virtual care can reduce disparities in health services in marginalized groups by increasing accessibility to services and providers, addressing inequitable access to health services, and respectfully responding to the diversity of Nova Scotians (including race, ethnicity, language, sex, sexual orientation, gender identity, (dis)ability, spirituality, age, geography, literacy, education, income).
  3. High-quality, safe, and appropriate care - Health professionals will collaborate with patients and other providers to ensure that the provision of virtual care does not limit access to necessary in-person care and is integrated into an overall plan of care.

Work in progress

The Nova Scotia Telehealth Network was implemented over twenty years ago as the first of its kind in Canada using videoconferencing to deliver patient care from one health care facility to another in the province. Since then, this service has evolved and undergone significant restructuring providing support for over 30 care programs including Primary Health Care, Mental Health & Addictions, Chronic Pain, Vascular Research & Surgery, Palliative Care, Geriatrics, Gastroenterology, Language Interpretation, and Neurology.

To support the immediate care needs of patients early in the COVID-19 pandemic Nova Scotia rolled out a province wide videoconferencing initiative through the NSHA Virtual Care Program enabling physicians and other care providers to provide primary care, acute care, mental health care, pharmaceutical care, dental care, optometry and ophthalmology services. Temporary fee codes enabled doctors/clinicians using Fee for Service to be paid the same as an office visit for treating patients using the phone or videoconferencing. The fee codes have since been extended, to support ongoing needs during wave 2 of the pandemic. To support access to care the province purchased, and NSHA distributed and supported, over 5500 videoconferencing licenses to various healthcare providers in the province.  To enable improvements to this service, the Department of Health and Wellness is conducting a phase 1 benefits evaluation with a focus on understanding barriers to use, satisfaction, efficiency, appropriateness, quality and patient safety. Canada Health Infoway provided funding and expertise for technology enablement and evaluation through the Access Atlantic Initiative.

During the first wave of the pandemic the Department of Health and Wellness collaborated with our health system partners on other important virtual care initiatives.

II. Initiatives under the Bilateral Agreement

Building on past initiatives and lessons learned the initiatives under the NS Virtual Care Bilateral Agreement will be patient-centered and focused on scaling virtual care in a meaningful way that improves the patient and provider experience, ensures quality of care while delivering value and improved health outcomes. From a technology perspective, privacy and security will continue to be high priorities in our planning. We will measure, monitor, evaluate and report on adoption, patient reported experiences, and quality of care.

The Virtual Care Priorities identified by the FPT Deputy Ministers in May 2020 are:

Nova Scotia’s investments in Virtual Care will be focused in 3 key areas:

  1. E-Mental Health - Improving Access to Mental Health and Addictions for Children, Youth and Adults
  2. Online Appointment Booking for Lab Tests and Diagnostic Services
  3. Strategy for Virtual Care - Videoconferencing and Secure Messaging
  1. E-Mental Health
    • Nova Scotia will use the Virtual Care Bilateral Agreement funding to support enhanced access to Mental Health and Addictions services.  Each initiative will align with one or more priorities, using the appropriate virtual care technology to deliver eMental Health services, such as videoconferencing, telephone or online programming, online tools for self-management and coaching.
    • In October 2019 the Province released the 2019-2021 Blue Print for Mental Health and Addictions:  https://novascotia.ca/dhw/mental-health/reports/Blueprint-for-Mental-Health-and-Addiction.pdf. The Blueprint for Mental Health and Addictions states “Consider evidence-based virtual care solutions, such as videoconferencing, telephone or online programming. We can use the internet to enhance access to mental health and addictions services by connecting primary health care providers—family doctors and nurse practitioners, for example—in underserved areas with specialists, and by connecting patients to the care they need…”
    • The primary focus of these initiatives is to support access to care in a private and secure manner that enhances the user experience. The 2019 Blueprint states: “Using virtual solutions in Nova Scotia could enhance access to services by augmenting or replacing traditional therapies and giving primary health care providers the knowledge and support they need to manage patients with mental health and addictions issues and complex conditions.”
      • Mental Health and Addictions Website Phase 2 Development - Increase resources available and enhance functionality in anticipation of the need for online resources during Wave 2.
      • Breaking Free - Addiction Treatment Online - Substance use/addiction and mental health software for online resources and support during Wave 2.
      • Online applications for youth - Increase resources available online for youth.
      • Support for First Responders/Frontline Healthcare/Long Term Care - Psychological support services including online self-management and coaching. Approximately 25,000 licenses.
    • These initiatives will contribute to addressing some of the unique needs of under-represented populations and improve equitable access to care in the province. Examples:
      • Translating the Mental Health and Addictions Website into French and Miꞌkmaq language to broaden access to services during wave 2.
      • Technology reach for vulnerable populations (LTC residents, MHA clients, etc.) to increase access to virtual/online services using mobile technology and wi-fi enabled devices.
    • There are numerous eMental Health services currently available or are in the planning stages, the following are a few examples:
    • Canada Health Infoway, through Access Atlantic have supported several eMental Health initiatives in Atlantic Canada.  The province will explore opportunities for funding and/or direct support for project management, joint technology procurement, interfacing, privacy and security assessments, and evaluations.
  2. Online Appointment Booking for Lab Tests and Diagnostic Services
    • As a result of COVID, when the health system started to open access to services, patients could no longer “walk-in” for blood collection or diagnostic images. There were safety concerns, infection prevention and physical distancing, with the high volume of patients presenting at blood collection locations across the province.  A phone system was put in place for people to call and book an appointment. Thousands of calls came into the call centre and the wait-time to book an appointment was well over two hours, and sometimes up to 4 hours.  People were also abandoning the phone process, due to the long wait times, and opting to go for longer periods of time without getting their tests. Attempts to manually schedule patients were overwhelming, despite the addition of more phone lines and staff.
    • In addition to the challenges faced with new COVID safety precautions required when delivering basic diagnostic services, there are also challenges in timely access to book a COVID test.
    • An online booking system for both regular diagnostics and COVID testing will enable timely access to both services and the results of the test.  In addition to online booking for COVID tests, the Province has implemented online access to negative COVID results.
    • Nova Scotia will use the federal funding to support enhanced access to services for blood collection, electrocardiograms and diagnostic imaging services by implementing a secure online appointment booking solution across the province.
    • An online booking solution focuses on a safe user experience.  Patients will be able to book or reschedule their own appointments, selecting a day and time that is most convenient. The online appointment model supports physical distancing within the waiting rooms. The system also manages the patient flow resulting in a predictable workload that allows for maximum efficiencies for staff scheduling and further reducing wait times.  Privacy and Security assessments as well as interoperability will be part of this initiative.
    • This system will be available to all Nova Scotians.  A phone-in option will still be available for patients who do not have access to the internet or technology.
    • Previous experience with an online appointment booking system was piloted at Northern Zone’s Colchester East Hants Health Centre and Central Zone’s Woodlawn Blood Collection Clinic, about four years ago. It demonstrated the value of using an online booking system by providing an enhanced patient experience with improved accessibility and minimal wait times. Feedback from patients was overwhelmingly positive. The booking system consistently showed a 7-minute wait time at the blood collection clinic, much less than the average one hour wait time prior to the online system and a less than two percent no show rate as patients were able to schedule appointments that were convenient for them and reschedule their appointments if they had a conflict.
    • In addition to support through the Virtual Care Bilateral Agreement, Canada Health Infoway may be able to provide support and funding for project management, interfacing, privacy and security assessments, and evaluations.
  3. Strategy for Virtual Care – Video Conferencing and Secure Messaging
    • Nova Scotia will use the federal funding to support an updated Digital Health strategy for virtual care that will include video conferencing and secure messaging. The video conferencing and secure messaging components of the strategy will initially focus on targeted physician groups who provide care to priority populations. Priority populations include those who do not have a health care provider, or their provider requires them to travel a significant distance. Priority populations also include those requiring access to specialists to accelerate decision making; and for mental health and addictions patients who can avoid the stigma of having to go into a health facility for support (note: E-Mental initiatives proposed in this Action Plan).
    • Access to care is a top priority for citizens, NSHA, IWK and the Department of Health and Wellness. To support Public Health measures early in the pandemic many physician offices looked at reducing the number of in-person visits to accommodate social distancing requirements, some physicians returning home from travel were required to self-isolate, offices with limited PPE had to limit in person hours and some retired physicians were offering to provide care but did not have practices. At the same time, NSHA began to explore virtual care clinics for unattached patients across the province and for patients requiring ambulatory care and post-operative care. These drivers supported an urgent need for virtual care tools to support provision of care in community offices and acute care facilities across the province.
    • In March and April, the province purchased over 5500 videoconferencing licenses for providers in the province.  This was a quick technical response to enable the continuation of patient care.  However, this may not be the best solution on a go forward basis.  Nova Scotia will work on a strategy to determine the best video conferencing solution for community-based providers, acute care providers and other providers who are not currently supported by these types of digital health solutions in the province.
    • The strategy will not only need to address the technology solutions including privacy and security requirements, but it will also need to address the policy considerations. The challenges with scaling virtual care have been well documented in Canada and include establishing funding models that balance appropriate compensation with accountability; questions regarding licensure, credentialing, and liability; the need for integrated technology that supports clinical workflow; need for change management  and other supports to encourage adoption and appropriate use; and, identity management solutions that validate patients and providers for privacy, regulatory compliance and compensation/audit purposes. Data and standards are foundational to evaluating virtual care services to ensure the effectiveness of care delivered virtually, to identify opportunities for improvement and to promote transparency and accountability.
    • Nova Scotia has been developing an interim Virtual Care Policy to ensure that publicly funded health services that are provided virtually complement in-person care services as part of the overall model of care.  While this policy currently focuses on synchronous care or virtual visits, it is important that a strategy for virtual care consider the role of secure messaging in the future. The policy will ensure that these services are provided to Nova Scotians in a manner that is safe, equitable, of high quality, and sustainable. Both synchronous and asynchronous virtual care will assist Nova Scotia to overcome challenges related to provision of primary care in rural and remote geographic regions.
    • Funding is required to complete the Strategy, technology and data architecture, privacy and security assessments for certified virtual care solutions and tools endorsed by the province, to support change management including the development of accredited CME programs and to implement phase 2 of a virtual care program in response to the pandemic and new normal.
    • In addition to the Virtual Care Bilateral Agreement funding, Nova Scotia will explore opportunities for funding and support from Canada Health Infoway related to project management, change management, privacy and technology assessments and benefits evaluation.

III. Funding allocation table

Funding allocation table
Total federal funding to Nova Scotia $5,868,500
  2020-21
(actual)		 2021-22
(actual)		 2021-23
(forecast)		 Total VC Bilateral
E-Mental Health $1,336,800 $486,500 $676,600 $2,499,900
Online Appt Booking for Lab & DS $1,322,700 $321,000 $550,000 $2,193,700
Strategy for Virtual Care N/A $553,200 $621,700 $1,174,900
Total per fiscal year $2,659,500 $1,360,700 $1,848,300 $5,868,500

IV. Performance measurement and expected results

A benefits evaluation with metrics will be developed for each of the three areas identified in the NS Virtual Care Bilateral Agreement.

  1. E-Mental Health: The NSHA and IWK are responsible for planning and delivering clinical services including services for mental health and addictions. They will be responsible for developing an evaluation plan with metrics for the initiatives within this funding envelop and the department will provide oversight and accountability for the funding.
  2. Online Appointment Booking for Lab Tests and Diagnostic Services: Building on the initial evaluation completed for the central and northern zone pilots, data will be collected and reported that includes no show rates, wait times, lab/DI through put using the online application vs phone. Data will also be collected on the patient and staff experience.
  3. Strategy for Virtual Care - Video Conferencing and Secure Messaging: Nova Scotia will work with CIHI to define a set of pan-Canadian indicators that will be used by CIHI to standardize and measure progress on virtual care implementation across Canada. Aligned with work in progress, Nova Scotia will complete a phase-one COVID-19 virtual care evaluation based on the approved logic model and performance indicators, by March 31, 2021. We have begun planning for a phase-two evaluation that will provide a deeper evaluation of quality, patient safety and appropriateness.
Summary of jurisdiction-specific indicators and expected results
Initiatives Outputs Target Outcome
Expansion of E-Mental Health Services
  • Access to online tools and services by target audience (cohort)
  • Patient experience and satisfaction by target audience (cohort)
  • Demonstrate increase in number of patients accessing virtual care tools and services by zone, cohort
  • Demonstrate positive patient experience using virtual care tools and services by zone, cohort
Online Appointment Booking for Lab Tests and Diagnostic Services
  • no show rates
  • wait times
  • down times
  • through put using the online application vs phone
  • patient experience
  • staff experience
  • Demonstrate efficiency improvements for the health system and the patient compared to walk in service.
Strategy for Virtual Care – Video Conferencing and Secure Messaging
  • Pan-Canadian - collaborate on the development of indicators with CIHI and report.
  • Nova Scotia - complete phase 1 virtual care evaluation to inform strategy and develop phase 2 logic model and indicators focused on quality, patient safety and appropriateness.
  • Demonstrate that virtual care when combined with traditional models of care can improve access, safety and patient experience.

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