Can Answers to the Health Workforce Crisis Be Found in Equity-Informed Digital Health?

In this paper, we describe current pressures on health human resources (HHRs) in the Canadian context and related factors that impact equity-deserving communities/populations. We explore issues of HHR challenges in rural, remote and urban underserved contexts and explore the associated benefits and challenges of incorporating digital health (DH). We present examples and evidence of integrating hybrid models of care as a means of supporting HHRs via DH in the publicly funded health system.

Health system use and outcomes of urgently triaged callers to a nurse-managed telephone service for provincial health information after initiation of supplemental virtual physician assessment: a descriptive study.

BACKGROUND: British Columbia's 8-1-1 telephone service connects callers with nurses for health care advice. As of Nov. 16, 2020, callers advised by a registered nurse to obtain in-person medical care can be subsequently referred to virtual physicians. We sought to determine health system use and outcomes of 8-1-1 callers urgently triaged by a nurse and subsequently assessed by a virtual physician. METHODS: We identified callers referred to a virtual physician between Nov. 16, 2020, and Apr. 30, 2021. After assessment, virtual physicians assigned callers to 1 of 5 triage dispositions (i.e., go to emergency department [ED] now, see primary care provider within 24 hours, schedule an appointment with a health care provider, try home treatment, other). We linked relevant administrative databases to ascertain subsequent health care use and outcomes. RESULTS: We identified 5937 encounters with virtual physicians involving 5886 8-1-1 callers. Virtual physicians advised 1546 callers (26.0%) to go to the ED immediately, of whom 971 (62.8%) had 1 or more ED visits within 24 hours. Virtual physicians advised 556 (9.4%) callers to seek primary care within 24 hours, of whom 132 (23.7%) had primary care billings within 24 hours. Virtual physicians advised 1773 (29.9%) callers to schedule an appointment with a health care provider, of whom 812 (45.8%) had primary care billings within 7 days. Virtual physicians advised 1834 (30.9%) callers to try a home treatment, of whom 892 (48.6%) had no health system encounters over the next 7 days. Eight (0.1%) callers died within 7 days of assessment with a virtual physician, 5 of whom were advised to go to the ED immediately. Fifty-four (2.9%) callers with a "try home treatment" disposition were admitted to hospital within 7 days of a virtual physician assessment, and no callers who were advised home treatment died. INTERPRETATION: This Canadian study evaluated health service use and outcomes arising from the addition of virtual physicians to a provincial health information telephone service. Our findings suggest that supplementation of this service with an assessment from a virtual physician safely reduces the overall proportion of callers advised to seek urgent in-person visits.

Integration of virtual physician visits into a provincial 8-1-1 health information telephone service during the COVID-19 pandemic: a descriptive study of HealthLink BC Emergency iDoctor-in-assistance (HEiDi).

BACKGROUND: British Columbia, like many jurisdictions, has a health information telephone service (8-1-1) to provide callers with information by registered nurses and help them decide whether to attend an emergency department or primary care clinic, or manage their concern at home. We describe a new service, HealthLink BC Emergency iDoctor-in-assistance (HEiDi), that partnered physicians available by videoconferencing with 8-1-1 registered nurses to support callers. METHODS: From Apr. 6 to Aug. 2, 2020, all callers to the 8-1-1 telephone service (available to anyone in BC) categorized as "seek care within 24 hours" by registered nurses were eligible for referral to HEiDi. HEiDi physicians ("virtual physicians") connected directly with callers via desktop videoconferencing software, assessed their health complaint, provided advice and suggested care disposition. We conducted a descriptive study and collected demographic characteristics, health concern and disposition determined by the virtual physician. RESULTS: HEiDi virtual physicians provided 7687 consultations. Most patients (n = 4439, 57.8%) were in the 20-64 age range, and 4814 (62.9%) were female. Common health concerns were related to gastroenterology (n = 1275, 16.6%), respiratory (n = 877, 11.4%) and dermatology (n = 874, 11.4%). From the 7531 calls with available data, 2548 (33.8%) callers were advised to attempt home treatment, 2885 (38.3%) to contact a primary care physician within 1 week, 1131 (15.0%) to attend an emergency department immediately and 538 (7.1%) to attend their primary provider now. INTERPRETATION: We found that virtual physicians were able to advise nearly 3 out of 4 (72.1%) patients away from in-person emergency or clinic assessment and 1 in 7 (15.0%) to seek immediate emergency department care. Virtual physicians can provide an effective complement to a provincial health telephone system.

Community-based research in action: tales from the Ktunaxa community learning centres project.

BACKGROUND: Rural communities, particularly Aboriginal communities, often have limited access to health information, a situation that can have significant negative consequences. To address the lack of culturally and geographically relevant health information, a community-university partnership was formed to develop, implement, and evaluate Aboriginal Community Learning Centres (CLCs). OBJECTIVES: The objective of this paper is to evaluate the community-based research process used in the development of the CLCs. It focuses on the process of building relationships among partners and the CLC's value and sustainability. METHODS: Semistructured interviews were conducted with key stakeholders, including principal investigators, community research leads, and supervisors. The interview transcripts were analyzed using an open-coding process to identify themes. RESULTS: Key challenges included enacting shared project governance, negotiating different working styles, and hiring practices based on commitment to project objectives rather than skill set. Technological access provided by the CLCs increased capacity for learning and collective community initiatives, as well as building community leads' skills, knowledge, and self-efficacy. An important lesson was to meet all partners "where they are" in building trusting relationships and adapting research methods to fit the project's context and strengths. CONCLUSIONS: Successful results were dependent upon persistence and patience in working through differences, and breaking the project into achievable goals, which collectively contributed to trust and capacity building. The process of building these partnerships resulted in increased capacity of communities to facilitate learning and change initiatives, and the capacity of the university to engage in successful research partnerships with Aboriginal communities in the future.

The impact of a personal digital assistant (PDA) case log in a medical student clerkship.

BACKGROUND: Medical education literature emphasizes that reflection and self-audit are pivotal steps in learning and that personal digital assistants (PDAs) have potential as decision support tools. DESCRIPTION: The purpose was to examine the efficacy of PDA-based resources and patient-encounter logging systems among 3rd-year medical clerks during pediatrics rotations. EVALUATION: Students in rotations were assigned to control (using paper-based logs and references) or intervention groups (using PDA-based logs and resources). Students completed pre- and postrotation Paediatrics Competency Surveys, participated in focus groups, and were compared on year-end examination grades. Use of PDA logs far outweighed that of paper logs (1,020 PDA logs and 87 paper logs). PDA logs were ranked significantly higher in enhancing learning and reflection than paper logs (t = 2.52, p < .01). PDA logs also facilitated specific learning experiences. CONCLUSION: PDA-based patient-encounter logs appear to be effective case documentation and reflection tools. The difference in number of logs between control and intervention groups demonstrates the utility of the PDA for "point-of-care" patient logging.

The impact of requiring completion of an online infection control course on health professionals' intentions to comply with infection control guidelines: A comparative study.

BACKGROUND: Ensuring good infection control practice in health care facilities is a constant concern, yet evidence shows that the compliance of health care professionals with proper procedures is lacking, despite the existence of guidelines and training programs. An online infection control module was developed to provide ready access to training. Controversy exists about whether successfully completing such a course should be mandatory or strongly encouraged for all health care professionals. The objective of the present study was to compare the perception of safety culture and intention to comply with infection control guidelines in professionals who were required by their supervisors to take the course, and those who did so voluntarily. METHODS: Survey responses on learning environment, safety climate and intention to comply with infection control guidelines in health care professionals who were required to take the course (supervisor-required group [n=143]) and those who took the same course voluntarily (voluntary group [n=105]) were compared. Because randomization was thought to be too difficult to implement in the policy context in which the study was conducted, significant differences between the two groups were taken into account in the analysis. RESULTS: Those required to take the course had a significantly better perception of the institutional safety climate (P<0.001), and had a higher reported intention to comply with infection control guidelines (P=0.040) than those who took the course voluntarily. DISCUSSION: Requiring that staff complete a 30 min interactive online infection control module increased their intention to comply with infection control guidelines compared with those who voluntarily accessed this material based on promotional material. Consideration should be given to making the successful completion of an online infection control module a requirement for all health care professionals.

Achieving social accountability through interprofessional collaboration: the Canadian medical schools experience.

Social accountability in the health professions is increasingly recognized as a necessary foundation for delivering effective healthcare. Inter- and intra-professional collaboration is critical to the process in order to transform intent into action. This article outlines the three-year program undertaken by a national collaboration among all 17 Canadian medical schools and their partners as they engaged in a journey leading to the incorporation of social accountability in an interprofessional context as the cornerstone of healthcare education and practice. An overview of the various dimensions of this project is discussed in order to shed light on how a national initiative in collaboration with local initiatives can synergistically work toward a common goal. Successes and challenges in working on a national level are reviewed with implications for future directions for interprofessional collaboration in healthcare based upon principles and values of social accountability.

Integrating social accountability into continuing education and professional development at medical schools: the case of an institutional collaborative project in Canada.

Social accountability is playing an increasingly significant role in medical education across Canada. This paper presents findings from a mixed methods evaluation of a collaboration project - Issues of Quality and Continuing Professional Development: Maintenance of Competence (CPDiQ) - undertaken by all 17 Canadian medical schools to promote social accountability in continuing professional development/continuing medical education programs. Data were gathered at three stages during the project to explore project participants' views and experiences of collaboration. Findings indicated there were four main benefits of this national collaboration: promoting a focus on social accountability; maximizing resources; enabling local learning; and developing a trusting foundation. Two key difficulties were identified: uncertainties about goals of collaboration; and communication challenges. CPDiQ was one important step amongst the many sustained, multifaceted initiatives required, to advance social accountability as a key goal of medical schools. The leadership within CPDiQ and provided by a national medical organization was instrumental in this initiative.

Social accountability in action: University-community collaboration in the development of an interprofessional Aboriginal health elective.

A survey of the health professional curriculum at the University of British Columbia revealed a need for improvements in education relating to Aboriginal health. At the same time, interprofessional education has been increasingly viewed as an essential aspect of sustainable health care reform. Interprofessional approaches to education and community practice have the potential to contribute to improvements in access to care, as well as health professional recruitment in underserved communities. While the benefits of interprofessional approaches have been identified, there are few published examples of the application of interprofessional learning and care in Aboriginal communities. This article describes the co-development by university and community partners of an accredited interprofessional, practice-based Aboriginal health course. Seed funding for this course was originally granted in November 2004 for a demonstration project led by the UBC Faculty of Medicine from a national Primary Health Care Renewal initiative focused on Social Accountability, namely "Issues of Quality and Continuing Professional Development: Maintenance of Competence" (referred to as CPDiQ project). This article presents findings from the development and implementation of this innovative course, run as a pilot during the summer of 2006 in two Aboriginal communities in British Columbia, Canada. Recommendations for integrating Aboriginal perspectives and foregrounding principles of social accountability in interprofessional health curricula are highlighted. In addition, successes and challenges are described related to garnering administrative and curricular support among the various health disciplines, interprofessional scheduling, and fostering cross-discipline understanding and communication.

Making interprofessional education work: the strategic roles of the academy.

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).