Optimizing the role of virtual care in emergency medicine

Aimee Kernick, Shelley L. McLeod, Shawn Mondoux, Justin N. Hall, Alecs Chochinov, Shirley Lee & Kendall Ho

Introduction

Emergency systems across Canada are grappling with critical challenges, including a shortage of skilled healthcare professionals, unexpected emergency department (ED) closures, prolonged wait times, and the extended ED boarding of admitted patients [1]. These issues contribute to suboptimal patient care, increase patient morbidity and mortality, and exacerbate workforce shortages [2].

Virtual care offers promising solutions by leveraging digital technologies such as video calls, phone consultations, and secure messaging to expedite and integrate the care of patients with urgent and emergent conditions [3]. While not a substitute for in-person emergency care or a solution to systemic access block, virtual care can serve as a valuable adjunct for patients with non-life-threatening concerns, particularly those in rural areas where facility closures limit access. It can also improve healthcare accessibility for individuals facing barriers to in-person care, such as patients with mobility challenges or those without a primary care provider or timely access to one [4,5,6].

If thoughtfully implemented and continuously evaluated, virtual care delivered by emergency care providers has the potential to become a fundamental component of the future emergency care landscape. However, its integration must be approached cautiously. Potential risks include exacerbating workforce strain, diverting resources from in-person emergency care, and creating inequities in care due to variations in digital access and technological literacy [7,8,9]. If implemented in an ad-hoc manner, without robust oversight and consideration of these risks, virtual care may yield unintended negative consequences, diminishing its overall benefits.

This position paper explores both the potential benefits and challenges of virtual care in emergency medicine, reviews the available evidence, and provides best-practice recommendations for its implementation and evaluation.

Recommendations

1. Virtual care should be purposefully integrated into a hybrid patient care system.

Rationale: Virtual care has the potential to help improve the patient experience and access to specialist knowledge but cannot replace in-person assessment and procedural skills. To ensure optimization of hybrid care, there should be direct referral options for rapid in-person assessment and specialist consultations, and clear lines of communication and information exchange, such as shared health information systems to ensure continuity and coordination of care.

Actionable steps:

• Develop provincial/territorial plans to integrate virtual care into emergency services as a supplement, rather than a substitute, for in-person care.

• Define clear referral pathways for rapid in-person assessments and specialist consultations, both within emergency medicine and across other specialties.

• Align virtual care integration with workforce planning to avoid exacerbating recruitment and retention challenges for in-person emergency care providers.

2. The role of emergency virtual care within an integrated emergency care system should be clearly defined.

   
   

Rationale: Clear definitions and standards are crucial for optimizing emergency services planning and managing public expectations. Virtual emergency care services are distinct from physical EDs. As such, health authorities should ensure that virtual care services are not labeled as emergency departments unless they have the necessary resources and expertise to directly manage all types of ED cases, including critically ill patients.

Actionable steps:

• Define minimum clinical, technological, and staffing requirements for virtual emergency services as part of an integrated health system plan.

• Support the development and adoption of clinical guidelines to ensure that virtual emergency services meet emergency medicine standards, including the availability of trained emergency physicians.

• Establish clear nomenclature and public communication guidelines to prevent the misrepresentation of virtual emergency care as a substitute for fully resourced EDs, ensuring proper understanding and use of these services.

3. Engage emergency care providers and emergency medicine system experts in the design, implementation, and evaluation of virtual care services.
   

Rationale: Hybrid care programs should be developed collaboratively with local providers, emergency medicine experts, virtual care providers, and health system leaders. Empower key stakeholders through early and regular engagement to foster strong relationships, promote clear communication, collaboration, and trust, leading to solutions that complement, rather than replace, existing services. To ensure workforce sustainability, virtual care deployment must not increase in-person staff workloads or hinder recruitment and retention.

Actionable steps:

• Promote collaboration and structured partnerships between virtual and in-person care providers to ensure enhanced care delivery, smooth patient handovers, coordinated follow-up care, and support for rural providers.

• Mandate shared health information systems (or information bridges) to allow real-time access to patient records, preventing care fragmentation between virtual and in-person providers.

4. Engage patients from diverse backgrounds in the design, implementation, and evaluation of virtual care services.

   
   

Rationale: Incorporating diverse patient perspectives is essential to improving the accessibility and usability of virtual care. Research demonstrates that user-centered design enhances effectiveness, inclusivity, and innovation. This approach helps address issues such as digital literacy, access barriers, and cultural sensitivity, ultimately building trust in virtual care.

Actionable steps:

• Advocate for the expansion of broadband infrastructure in rural and remote areas to address digital barriers and ensure reliable access to virtual care.

• Implement digital literacy initiatives to support patients, especially seniors and marginalized communities, in navigating virtual care services.

• Design virtual care services to be accessible to all patients by offering services in multiple languages, ensuring cultural appropriateness, and accommodating diverse accessibility needs.

5. Standardize virtual care data reporting across Canada.
   

Rationale: Standardizing healthcare data nationwide will help drive policy innovation and optimize hybrid care. Use the Quintuple Aim framework to evaluate hybrid emergency services, scaling effective models and refining or retiring those that offer no net benefit (or do harm) to the healthcare system. This framework should track patient demographics, service use, health outcomes, human resources, and cost-effectiveness. A centralized data-sharing system between private providers and public health authorities will enable real-time monitoring, support evidence-based policies, and ensure equitable access to virtual care.

Actionable steps:

• Standardize data collection across all virtual emergency care programs to assess patient demographics, service utilization, outcomes, and cost-effectiveness.

• Develop a centralized data-sharing system between private virtual care providers and public health authorities to ensure accountability, transparency, and real-time monitoring.

• Evaluate virtual emergency services using the Quintuple Aim framework to ensure alignment with system-wide goals of improving the patient experience, health outcomes, cost efficiency, provider well-being, and equity.

6. Standardize and regularly update virtual care guidelines based on emerging evidence.
   

Rationale: Policymakers should mandate regular updates to virtual care guidelines to incorporate the latest evidence on clinical effectiveness, patient outcomes, and best practices. This includes defining which patient groups and medical conditions are best suited for virtual care, ensuring that patients receive the most appropriate care modality. Standardized, evidence-based guidelines will help balance patient preferences, clinical appropriateness, and equitable access to care.

Actionable steps:

• Require ongoing policy updates based on emerging evidence regarding clinical effectiveness, safety, and best practices in virtual emergency care.

• Define patient conditions and clinical care contexts that are best suited for virtual emergency consultations to ensure appropriate use of virtual services and avoid misuse.

• Implement a framework for scaling effective models of virtual emergency care while phasing out ineffective approaches, ensuring continual improvement and optimization.

7. Align virtual care funding models with system sustainability
   

Rationale: Policymakers must adopt a “whole system” perspective when designing funding models for virtual care, ensuring that virtual care funding does not reduce support for in-person care. Virtual care should complement, not replace, in-person services, especially for complex cases. Funding models should align reimbursement with the needs of the emergency care system, to ensure resources are not diverted away from essential in-person care and maintain a sustainable healthcare system.

Actionable steps:

• Ensure virtual emergency care funding strengthens long-term system capacity without compromising necessary resources for in-person emergency departments.

• Create transparent, accountable funding agreements for virtual emergency services that prioritize public healthcare system needs over private sector incentives.

• Align reimbursement structures for virtual emergency care with health system outcomes and cost-efficiency metrics.

• Share effective funding models for virtual emergency care across Canada to promote cross-jurisdictional knowledge exchange and adoption to optimize value for money.

Summary of Recommendations

Next Steps

While the virtual path ahead presents opportunities for tremendous improvements in health delivery, it is not without risk. We urge all health ministries, regional health authorities, and policymakers involved in the design, implementation, funding, and evaluation of virtual care programs to thoughtfully consider the recommendations in this position statement. CAEP is committed to working broadly with all stakeholders to optimize the development and delivery of hybrid emergency care.

Conclusion

When designed as part of an integrated hybrid model, virtual emergency care offers a pivotal opportunity to enhance access and support emergency care providers across Canada, particularly in rural and remote areas. It can extend the reach of emergency medicine expertise to these areas, ensuring timely care while maintaining high clinical standards. At the same time, there is an urgent need to generate empirical evidence that virtual emergency care delivers on its potential and does not draw the already-depleted emergency medicine workforce to lesser-value, non-integrated virtual care options. Thoughtful planning and implementation, rooted in collaboration and data-driven evaluation, could enable virtual emergency care to complement in-person services, strengthen emergency care systems, and improve patient outcomes. Adherence to the Quintuple Aim framework will ensure that healthcare planners and funders prioritize high-value, cost-effective, equitable hybrid emergency care initiatives that improve patient and population and health, while supporting and optimally utilizing our invaluable health workforce.

Note: Please refer to the full manuscript, available in the online supplementary material, for further background, references, and supporting detail.

Conflict of interest

KH, SM, and JNH declare a potential conflict of interest that they receive program funding support related to the implementation and/or evaluation of virtual care initiatives. Otherwise, all authors declare no other conflicts of interest relevant to this work.

Data Availability Statement

No new data were generated or analyzed in the development of this position statement. The background literature reviewed is cited in the reference list. Additional references and background information is provided in the online supplementary material.