CADTH Health Technology Review

Virtual Care Use in Primary Care or Specialty Care Settings

Rapid Review

Authors: Ransi Nayakarathna, Heather Neilson, Danielle MacDougall, Tara Cowling

Key Messages

• Five evidence-based guidelines met the eligibility criteria for this report. Of the 5 guidelines, 2 provided recommendations on rheumatology practice, 1 on stroke, 1 on oncology, and 1 on digital innovations for all areas of health; none of them focused on primary care specifically. Three were developed in the context of COVID-19.

• While all 5 guidelines were informed by a systematic literature search, some specific recommendations were based on expert consensus, given the absence of literature on the respective topics. The quality of evidence and strength of recommendations, where available, were generally assessed to be low across the guidelines.

• The evidence-based guidelines provided recommendations across various aspects of virtual care delivery including population considerations, patient conditions, and the types of care that can be offered virtually. They also provided recommendations on when to offer or discontinue virtual care, on patient privacy, and on staff training. One guideline provided a recommendation on fees and reimbursement.

• Multiple evidence-based guidelines stated that virtual care should complement rather than replace in-person care, and that virtual care should only be implemented when adequate resources and personnel are available and patient privacy can be secured.

Context and Policy Issues

Virtual care has been defined as any interaction between patients and members of their circle of care that occurs remotely, using any form of communication or information technologies, with the aim of facilitating or maximizing the quality or effectiveness of patient care.¹ Also known as direct-to-patient virtual care or e-visits, virtual care may be synchronous (i.e., happening in real-time) or asynchronous (i.e., not happening in concurrent time) in nature.² Included in this definition are telehealth services, audio conferencing (e.g., telephone), video conferencing (e.g., Zoom), secure messaging (e.g., text), and patient monitoring systems. The term telehealth refers to the remote delivery of health care and related clinical or non-clinical services such as patient-to-provider interactions, provider-to-provider interactions, health care education, self-care, and health information services using telecommunication technologies such as computers, mobile devices, or wearable devices.³ Telemedicine refers to a practice of medicine involving the use of information and communication technologies by a health care provider to administer health care to patients.³ Of note, there is variability in how virtual care and other terms in this space such as telehealth and telemedicine are defined across settings and regions.

The COVID-19 pandemic led to an unprecedented rapid increase in the use of virtual care across multiple specialties and settings in Canada. For example, during the first wave, telemedicine was responsible for an estimated 77% of all ambulatory visits in Ontario.⁴ At the time, the aim of virtual care in Canada was to maintain health care delivery to the population while physically distancing to reduce the spread of COVID-19. Guidance for health care providers quickly emerged, such as the Canadian Medical Association’s Virtual Care Playbook for Canadian physicians.⁵ An early analysis of Canada’s pandemic response by Health Canada suggested that virtual care should remain a publicly funded service, and “while change was forced upon us by the pandemic it was, in many cases, long overdue”.⁶ Even before the COVID-19 pandemic, Canada’s experience and interest in virtual care had been growing. Guidance for health care professionals on the use virtual care had already been published,⁷ evaluation studies had been done,⁸ and strategic planning (e.g., in oncology) had already included virtual care.⁹

Yet issues and uncertainties remain regarding the appropriateness of virtual care for long-term implementation. For various reasons, some patients prefer not to receive virtual care,² and for many, certain care modalities are unavailable or not easily accessible. For example, patients living in rural areas with limited internet access, older adults, and patients living with disabilities may face challenges engaging with technology, and out-of-pocket expenses may be relatively high for patients with a lower household budget.¹⁰ There may also be implications for clinical processes and for clinical quality and safety; for example, health care providers may be concerned about the inability to conduct in-person physical examinations.¹¹ Clinicians’ experiences with technology and its effects on their work, as well as the financial and operational impact of virtual care including costs and payment issues, medical education, and licensure, also need to be considered.¹⁰

To effectively integrate virtual care into the health care delivery continuum, there is a need to first understand what is and what is not an appropriate use of virtual care. Evidence syntheses based on the peer-reviewed literature could inform future decisions about which virtual services should be maintained, either through continual or increased funding, and which virtual services should be stopped. It is possible that the quantity and quality of existing evidence varies by health care setting (e.g., primary versus specialty care) and by health condition (e.g., diabetes versus oncology).

The objective of this report is to summarize recent evidence-based guidelines regarding the appropriate use of virtual care for individuals using primary care or specialty care services.

Research Question

What are the evidence-based guidelines regarding the appropriate use of virtual care for individuals using primary care or specialty care services?

Methods

Literature Search Methods

A limited literature search was conducted by an information specialist on key resources including MEDLINE, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concept was virtual care. CADTH-developed search filters were applied to limit retrieval to guidelines. Where possible, retrieval was limited to the human population. The search was completed on June 14, 2022 and limited to English-language documents published since January 1, 2017.

Selection Criteria and Methods

One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1, if they were duplicate publications, or if they were published before 2017. Guidelines with unclear methodology (e.g., systematic literature review not reported) were also excluded.

Critical Appraisal of Individual Studies

The included publications were critically appraised by 1 reviewer using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument¹² for guidelines. Summary scores were not calculated for the included publications; rather, the strengths and limitations of each included publication were described narratively.

Summary of Evidence

Quantity of Research Available

A total of 684 citations were identified in the literature search. Following screening of titles and abstracts, 601 citations were excluded, and 83 potentially relevant reports from the electronic search were retrieved for full-text review. Two potentially relevant publications were retrieved from the grey literature search for full-text review. Of these potentially relevant articles, 80 publications were excluded for various reasons, and 5 publications met the inclusion criteria and were included in this report. Appendix 1 presents the PRISMA¹³ flow chart of the study selection.

Additional references of potential interest, including additional publications that did not meet our eligibility criteria, are provided in Appendix 5. The majority of the additional references were practice guidelines developed by various organizations that did not use or report using an evidence-based approach. An Executive Summary of the recommendations from these practice guidelines is provided for primary care and musculoskeletal care, along with a list of the publications and their recommendations (Table 5). A list of citations for other areas of health care, where virtual care has been reported, is also included in Appendix 5.

Summary of Study Characteristics

Overall, 5 evidence-based guidelines met the eligibility criteria and were included in this report.^14-18 Additional details regarding the characteristics of included publications are provided in Appendix 2.

Study Design

Five guidelines were eligible for inclusion in this report. The first guideline, published in 2022 by the Asia Pacific League of Associations for Rheumatology (APLAR), provided evidence-based recommendations for telemedicine in rheumatology.¹⁴ The second guideline, published in 2022 by a committee from the Arab League of Associations for Rheumatology (ArLAR),¹⁶ provided general principals and best practice guidelines for telehealth in rheumatology. The third guideline, published in 2021 by the American Society of Clinical Oncology (ASCO), provided standards for telehealth in oncology.¹⁷ The fourth guideline, first published in 2019 by the WHO,¹⁸ provided 9 priority emergent digital innovation recommendations intended for health system strengthening. The fifth guideline, published in 2017 by the Heart and Stroke Foundation for Canadian Stroke Best Practices, provided evidence related to the establishment of Telestroke systems and the use of Telestroke.¹⁵ The methods used to develop the guidelines are described below.

The APLAR guidelines¹⁴ focused on the practice of telemedicine in rheumatology. A systematic literature review was conducted, and evidence from randomized controlled trials and observational studies was considered. The quality of evidence was appraised using GRADE (ranging from A [highest] to D [very low]), and the level of evidence was indicated according to the Oxford Levels of Evidence (ranging from 1 [systematic review of randomized trials] to 5 [mechanism-based reasoning]). Recommendations were developed using a modified Delphi technique to establish consensus. When evidence was limited, recommendations were created based on clinical expertise and practical experience of working group members, to provide practical guidance in the areas of telemedicine that are most relevant to rheumatology practice. Guideline validation was not reported. Strength of the recommendations was not reported.

The ArLAR Best Practice Guidelines,¹⁶ for telehealth in rheumatology, were based on a systematic literature review of available guidelines and studies. Levels of evidence (LOEs) were indicated according to the Oxford Centre for Evidence Based Medicine (ranging from 1 [highest] to 5 [lowest]). Based on the available literature, general principles and best practice statements were drafted by 2 authors. A multidisciplinary task force then assessed the guidelines using a modified Delphi process. The final draft was validated by a core steering committee and subsequently reviewed by another committee, advisor, and expert. Strength of the recommendations was not reported.

The ASCO Standards and Practice Recommendations,¹⁷ for telehealth in oncology, were based on a systematic literature search combined with an expert panel consensus. Following an initial scoping review and consensus on oncology-specific topics to be included, a systematic literature search was conducted for relevant systematic reviews or primary studies. The quality of included studies was assessed using a variety of instruments (e.g., adaptation of Critical Appraisal Skill Program checklist for qualitative research, modified Hawker et al. tool, adapted Cochrane Collaboration Back Review Group Checklist, GRADE, Cochrane risk of bias tool, Downs and Black checklist). Literature search results were combined with an expert panel consensus to develop the standards, followed by a 2-week period allowing the public to review and comment. The quality of evidence and strength of the recommendations were not reported. Standards were subsequently reviewed by an expert panel and ASCO Quality of Care Council and the ASCO Board of Directors.

The WHO Digital Health Guidelines were based on evidence from a systematic literature review.¹⁸ The 2 main types of evidence considered were: evidence on the effectiveness of digital health interventions, based on randomized controlled trials, non-randomized studies, controlled before-and-after studies, and interrupted time series studies; and evidence on the factors affecting the acceptability, feasibility, and implementation of digital health interventions, based on qualitative studies. The certainty of the quantitative evidence was classified using GRADE criteria (ranging from high to very low), and confidence in the qualitative evidence was assessed using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual; ranging from high to very low). Both evidence and expert opinions were used to develop the recommendations and, when minimal evidence existed, a post-deliberation consensus position of the Guidelines Development Group was considered. An external review group peer-reviewed the final guideline document. Strength of the recommendations was not reported.

The Canadian Stroke Best Practice Recommendations consisted of evidence-based recommendations for Telestroke systems.¹⁵ An interprofessional writing group developed the recommendations based on a systematic literature search. Systematic reviews, meta-analyses, randomized controlled trials, and observational studies were included, where available. Recommendations based on the evidence identified were formulated by the working group through discussion and debate, and additional research of value that was identified through these discussions. Evidence supporting each recommendation was assigned a level (ranging from A [highest] to C [lowest]), according to a table of criteria defined by the working group. Recommendations were subsequently reviewed internally by the Canadian Stroke Best Practices Advisory Committee, as well as externally. Strength of the recommendations was not reported.

Country of Origin

The APLAR guidelines are intended for clinical practice in the Asia Pacific region; the ArLAR guidelines are intended for use in the Arab region; the ASCO recommendations are intended for use in the US; the WHO guidelines are intended for global use; and the Telestroke recommendations are intended for use in Canada.

Patient Population

The target population for the APLAR recommendations¹⁴ are rheumatology patients and clinicians in the Asia Pacific region, and the intended users are clinicians in that region.

The ArLAR guidelines¹⁶ target patient populations with rheumatology conditions in the Arab region, and the intended users are rheumatologists in that region.

The ASCO recommendations¹⁷ are intended for oncologists, nurses, advanced practice providers, allied health professionals, and administrators involved in cancer care delivery. The target population for these standards include individuals undergoing diagnosis, treatment, survivorship, or palliative care for cancer.

The WHO guidelines¹⁸ are intended for health system decision-makers and public health practitioners, to help them develop a better understanding of digital health interventions with an evidence base, to support health system needs. These guidelines are also beneficial to investors who resource digital health systems, as implementation and development partners. The guidelines are aimed at strengthening the health system for the general patient population and all health conditions.

The Canadian Stroke Best Practice Recommendations¹⁵ are intended for use by health care professionals across all disciplines who treat patients not living close to a specialized stroke centre. The recommendations are intended to support decision-making for patients who are potential candidates for acute endovascular treatment and to support the use of Telestroke in stroke prevention and rehabilitation services. These recommendations also provide guidance for health system decision-makers and planners.

Interventions

The interventions considered within the APLAR guidelines¹⁴ were for telemedicine in rheumatology practice, where telemedicine was defined as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities” (p.248).¹⁴ The ArLAR guidelines¹⁶ considered best practice interventions for teleconsultation in rheumatology, where teleconsultation was defined as the “synchronous exchange of medical information between a patient and a rheumatologist via audio or audiovisual electronic communication, to improve the patient's health status” (p.381).¹⁶ The ASCO recommendations¹⁷ considered interventions for telehealth in oncology; the definition of telehealth was not reported. The WHO guidelines¹⁸ examined 9 priority emergent digital innovations that target health system strengthening, including the use of telemedicine, targeted client communication, health worker decision support, digital tracking, and training. The Canadian Stroke Best Practice Recommendations¹⁵ considered interventions related to forming Telestroke systems and the use of Telestroke, which was defined as the use of remote telecommunications in stroke care.

Outcomes

The primary outcomes considered within the APLAR guidelines¹⁴ were disease remission, disease activity indices, and patient-reported outcomes. Secondary outcomes included adverse events, patient satisfaction, drug compliance, drug dosage optimization, improvement in knowledge, attitude, practices, and cost-effectiveness. Additional outcomes considered were latency to diagnosis and latency to rheumatology referral.¹⁹

The outcomes considered within the ArLAR guidelines¹⁶ included the main barriers and facilitators to telehealth in the Arab region, general principles, best practice guidelines, and a practical toolkit for implementing telehealth services in rheumatology clinics.

The ASCO recommendations¹⁷ considered the outcomes of in-person versus telehealth visits on patient outcomes, workflow and implementation considerations for telehealth applications, patient selection, standards, establishing physician patient relationship, role of advanced practice providers and allied health professionals in oncology telehealth interventions, virtual multidisciplinary cancer conferences, and teletrials and/or virtual participation in oncology clinical trials.

The outcomes of relevance to this report that were considered in the WHO guidelines¹⁸ were health system improvements, including an assessment of the benefits, harms, acceptability, feasibility, resource use, and equity considerations.

The Canadian Stroke Best Practices Recommendations¹⁵ considered the organization of Telestroke systems for the hyperacute phase of stroke and for ongoing stroke assessment and management. Staff training, ongoing education, barriers to Telestroke, and updated versions of a previously developed set of clinical practice recommendations on equipment accessibility and data privacy considerations were also considered.

Summary of Critical Appraisal

All 5 articles reported on the evidence-based methodology that was applied when deriving recommendations. In all 5 guidelines, the objectives and population of interest were noted, and all 5 guidelines clearly described the health questions of interest. Additionally, 4 guidelines^15-18 clearly defined the target users of the guideline and included views of the target population and relevant professionals in the guideline development process. The remaining guideline (i.e., APLAR¹⁴) did not provide explicit details on these areas. The recommendations provided by all guidelines were specific and clearly identifiable. The methods of guideline development (e.g., selection criteria and process for consensus) were consistently reported in all 5 guidelines. Although 4 out of 5 guidelines stated the need or intention to update guidelines periodically,^14,15,17,18 none of them except the WHO guidelines¹⁸ explicitly described the process for updating. All guidelines lacked monitoring and/or auditing criteria. Additional details regarding the strengths and limitations of included publications are provided in Appendix 3.

Summary of Findings

Three of the 5 guidelines (i.e., APLAR,¹⁴ ASCO,¹⁷ and ArLAR¹⁶) were published in the context of the COVID-19 pandemic. Two guidelines provided recommendations for rheumatology practice,^14,16 1 for oncology,¹⁷ 1 for digital innovations in all areas of health,¹⁸ and 1 for stroke.¹⁵ Summaries of recommendations in each area are provided below according to the main outcomes of interest to this report. Appendix 4 presents the specific recommendations along with the quality of the supporting evidence, where available.

Recommendations for Rheumatology Practice

Two guidelines provided recommendations or standards for rheumatologists on different aspects of virtual care. The 2022 APLAR guidelines¹⁴ included 13 recommendations and the 2022 ArLAR guidelines¹⁶ included 3 general principles and 12 best practice standards.

Population considerations: The APLAR guidelines¹⁴ recommend that in new patients without a diagnosis, telemedicine should be limited to early guidance (GRADE C); that all patients can be assessed for eligibility for telemedicine follow-up for up to 12 months (GRADE B); that having a pre-teleconsultation triage system may help to identify patients that would not benefit from telemedicine (GRADE C); and that teleconsultations with a health care professional, co-located with the patient, is preferred (GRADE C). The ArLAR guidelines¹⁶ report that teleconsultation can be used for patients who are home-bound, live in remote areas or underserved communities, or who need to adhere to social distancing restrictions (LOE-3).

Patient conditions: Both guidelines provide recommendations or standards for access and continuity of care for patients with rheumatic diseases. The ArLAR guidelines report that telehealth can help some patients adhere to the management plan, and this is likely to improve disease outcomes in some selected disease states (LOE 2).¹⁶

Types of virtual care: The APLAR guidelines conditionally recommend the adoption of video consultation over other forms such as telephone or asynchronous messaging via email, short message services, and other internet-based services (GRADE C).¹⁴

When to offer: The APLAR guidelines recommend telemedicine consultations over unsupervised medication changes when normal health services are disrupted (GRADE B).¹⁴

When to discontinue: The APLAR guidelines conditionally recommend scheduling an in-person consultation when a rheumatologist encounters unexplained symptoms or has difficulty in assessing the patient, or if the rheumatologist or patient perceives a gap in communication during the telemedicine consultation (GRADE C).¹⁴

Apart from these main outcomes of interest, both guidelines provide recommendations on protection of data privacy/confidentiality (APLAR GRADE B, ArLAR LOE 5), on the importance of using patient-reported outcomes (APLAR GRADE B, ArLAR LOE 3), and on staff training (APLAR no evidence, ArLAR LOE 5). Further the APLAR guidelines recommend that if for in-person care a treat-to-target approach is practiced, a similar approach should be practiced for telemedicine (GRADE C). The ArLAR guidelines provide standards on informed consent (LOE 5), shared decision or choice between care provider and patient (LOE 5), documentation (LOE 5), safe prescription (LOE 5), teleconsultation fees and reimbursement being similar to in-person visits (LOE 5), ethical considerations similar to in-person care (LOE 5), and the improvement of infrastructure (LOE 5). Further the ArLAR guidelines encourage research projects to assess the implementation of telehealth and the resulting disease outcomes in the Arab region (LOE 5).

Recommendations for Oncology Practice

The 2021 ASCO recommendations¹⁷ provided 15 standards for oncology practice. The quality of evidence was not reported.

Population considerations: The standards were developed for use across the spectrum of care delivery in individuals with cancer.

Types of virtual care: Telehealth via telephone or videoconferencing is recommended when infrastructure and personnel are available. Diagnosis (skin lesions) via asynchronous transmission of images can be done. Individualized orientation should be provided to both parties for the specific type of technology that will be used (e.g., mobile phone, web-based). Asynchronously delivered interventions, such as automated reminders delivered via text message, can be used. Patients and caregivers should be involved in user testing of new interventions (e.g., apps) whenever possible.¹⁷

When to offer: Telehealth is recommended for treatment or long-term management of various conditions including new patient consultations (followed by in-patient care), prescribing and management, prechemotherapy evaluations, and follow-up. It is also recommended when care access issues exist for family conferences, genetic counselling, and second opinions.¹⁷ An extensive list of services that are reasonable to offer via telehealth versus those that may be preferred in person is provided in Appendix 4.

Apart from the above standards, guidance is also included on when to offer in-person consultation, documentation, policies and standard operation procedures; the importance of technology support during the consultation; evaluations of key performance indicators; establishment of the doctor-patient relationship; use of advanced practice providers and allied health professionals; virtual multidisciplinary cancer conferences; and teletrials and/or virtual participation in oncology clinical trials.

Recommendations for Digital Interventions

The 2019 WHO guidelines¹⁸ provided evidence on 9 priority emergent digital innovations. Six of the 9 recommendations are relevant to this report.

Population considerations: The recommendations were developed for use by policy-makers and investors to strengthen the health systems for all populations.¹⁸

Patient conditions: The 6 recommendations of relevance to this report are for all health conditions. One recommendation that targeted 5 specific areas of health (i.e., sexual, reproductive, newborn, child, and adolescent health) recommended the use of digital interventions only when potential concerns about sensitive content and data privacy can be addressed.¹⁸

Types of virtual care: Telemedicine and mobile devices are the types of interventions included in the guideline.¹⁸

When to offer: Telemedicine (both client-provider and provider-provider interactions) is only recommended to complement, rather than replace, in-person care, in settings where patient safety, privacy, traceability, accountability, and security can be monitored. Health worker decision support tools through mobile devices are recommended only for tasks that are defined within the scope of practice for the health worker. Digital tracking of patients’ or clients’ health status and services through mobile devices is recommended only when the health system can support the implementation of these intervention components in an integrated manner and when potential concerns about data privacy and transmitting sensitive content can be addressed. The provision of training to health workers via mobile devices is recommended as a complement, rather than a replacement, for traditional methods of delivering continued health education and post-certification training.¹⁸

Recommendations for Stroke Practice

One guideline (i.e., Canadian Stroke Best Practice Guideline)¹⁵ provided recommendations for stroke practice. This 2017 guideline includes 23 main recommendations with several subcategories.

Population considerations: The Canadian Stroke Best Practice Guidelines recommend that Telestroke services should be encompassed in a combined stroke services delivery plan to address hyperacute stroke care, acute stroke care, stroke prevention, rehabilitation, home-based care, and ambulatory care to support optimal patient recovery and family support in all geographic locations in Canada (LOE C).¹⁵

Patient conditions: Telestroke can be used for hyperacute and acute stroke assessment, diagnosis, and treatment, including acute thrombolytic therapy and decision-making for endovascular therapy (LOE B). Protocols should be available for patient transfer criteria to advanced care facilities (e.g., endovascular [if available] and neurosurgical intervention) (LOE C).¹⁵

Types of virtual care: Videoconferencing and teleradiology systems can be used to support screening and decision-making regarding eligibility for endovascular therapy (LOE B). The guidelines also include the importance of real-time 2-way audiovisual communication (LOE B). The benefits of telephone consultation without video are not well-established (LOE C).¹⁵

Additional recommendations are that consultation should be performed by a physician with specialized training in hyperacute stroke management and must have timely access to diagnostic-quality images (e.g., brain CT, CTA; LOE A). Also, referring physicians should follow an established protocol with major steps for recanalization therapies (LOE A). Apart from this, there are recommendations regarding the importance of processes, protocols, and referral systems available for Telestroke consultation (LOE B); for staff training and continuing education (LOE C); for shared decision-making (LOE C); for access for follow-up guidance to referring site (LOE C); and for documentation (LOE C).

Limitations

There are several limitations to this body of evidence. First it should be noted that among the recommendations, a wide variety of clinical areas are addressed (2 guidelines were intended for virtual care in rheumatology, 1 for oncology, 1 for stroke, and 1 for general health systems). The limited volume in each category and diversity in the recommendations identified limited the synthesis across the guidelines included in this report. Further, as no guidelines in primary care were identified, it was not possible to summarize recommendations for virtual care in primary care. It should also be noted that, while all 5 guidelines were informed by a systematic literature search, some specific recommendations were based on expert consensus only, given the absence of literature on the respective topics. Further, where available, quality of evidence and strength of recommendations were generally assessed to be low across the guidelines. Finally, while the included guidelines were evidence-based, these were primarily intended for non-Canadian populations (except for the WHO guidelines¹⁸ and Canadian Stroke Best Practice Recommendations¹⁵). Thus, they may not be generalizable to the Canadian population. Due to the limited volume of evidence, some consensus-based recommendations, and limited generalizability, caution should be used when translating the findings of this report into Canadian clinical practice.

Conclusions and Implications for Decision or Policy-Making

Five guidelines met the inclusion criteria for this rapid review and were included in this report. The included evidence comprised 2 sets of evidence-based guidelines on virtual care in rheumatology,^14,16 1 on Telestroke,¹⁵ 1 on telehealth for oncology,¹⁷ and 1 for digital interventions for all areas of health.¹⁸ None specifically focused on virtual care for primary care settings. The recommendations are wide-ranging, addressing various aspects of virtual care, including when to offer or discontinue virtual care, patient privacy, and staff training. The guidelines addressed the utilization of virtual care across multiple geographic locations, patient conditions, and virtual care modalities. One guideline provided a recommendation on fees and reimbursement.

Three out of the 5 guidelines were developed in the context of COVID-19, after the demand and usage of virtual care had increased.⁴ These guidelines reported on various types of virtual care, including but not limited to video, telephone, and mobile devices. All 5 guidelines provided recommendations on when and how to use virtual care, on privacy and confidentiality, on staff training, and on education or research of relevance to virtual care. The WHO guidelines on digital interventions¹⁸ specifically addressed investors and policy-makers, offering key considerations for acceptability and feasibility.

The recurring themes among the guidelines were that virtual care should be a complement rather than a replacement to in-person care, and that virtual care should only be implemented when adequate resources and personnel are available and patient privacy and confidentiality can be secured. While the guidelines identified the convenience, flexibility, and potential time and cost savings associated with virtual care, there was limited evidence describing the potential barriers or limitations to virtual care, such as issues with internet access, technical support and infrastructure, and the appropriate use of virtual care in underserved populations.

CADTH has published many reports on various topics within virtual care, including virtual care evaluation approaches,¹⁰ enablers for virtual visits,²⁰ effectiveness of and guidelines for telehealth-delivered supervised consumption services,²¹ virtual care for patients with schizophrenia/psychosis,²² perspectives and experiences of virtual care,²³ virtual waiting rooms,²⁴ and remote presence versus videoconference.²⁵ CADTH’s evidence bundle on Digital Health contains additional reports on telehealth and telemedicine.²⁶ More recently, CADTH published 2 reports on evidence-based guidelines relevant to specific clinical areas: 1 was on virtual clinical assessments for adults with back pain, which identified no relevant guidelines²⁷; the other was on virtual oncology visits, which identified 4 relevant guidelines.²⁸ Notably, guidelines from the Clinical Oncology Society of Australia²⁹ and the National Institute for Health and Care Excellence in the UK,³⁰ included in the latter report,²⁸ are not in the current report on account of different literature searches conducted (i.e., the previous CADTH report²⁸ specific to oncology was able to conduct more focused literature searches). Finally, also of note, a previous CADTH report¹⁰ identified no evidence discussing approaches to evaluating virtual care in primary care from Indigenous Peoples’ perspectives in Canada or in other countries, in line with the current report.

The findings of this review should be interpreted with caution, given that: the quality of evidence, where available, was generally assessed to be low; the strength of the recommendations was not reported; and consensus-based recommendations were made when evidence was lacking. Future guidelines on virtual care that are supported by high-quality evidence are needed in both primary care and specialty care settings and for all populations and conditions. As new evidence becomes rapidly available in this highly evolving field, living guidelines may prove useful. In fact, the WHO proposed updating its guidelines as a living document.¹⁸

Virtual care is expected to continue to play a significant role in Canada’s health care system and will likely evolve over time. Additional studies and guidelines of high quality and strength will help in guiding its appropriate use.

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15.Blacquiere D, Lindsay MP, Foley N, et al. Canadian Stroke Best Practice Recommendations: Telestroke Best Practice Guidelines Update 2017. Int J Stroke. 2017;12(8):886-895. PubMed

16.Ziade N, Hmamouchi I, El Kibbi L, et al. Telehealth in rheumatology: the 2021 Arab League of Rheumatology Best Practice Guidelines. Rheumatol Int. 2022;42(3):379-390. PubMed

17.Zon RT, Kennedy EB, Adelson K, et al. Telehealth in Oncology: ASCO Standards and Practice Recommendations. JCO Oncology Practice. 2021;17(9):546-564. PubMed

18.WHO guideline: recommendations on digital interventions for health system strengthening. Geneva (CH): World Health Organization; 2019: https://www.who.int/publications/i/item/9789241550505. Accessed 2022 Jul 19.

19.Adnan A, Alnaqbi K, Chen Y, et al. Systematic review informing the APLAR recommendations on the practice, approach and use of telemedicine for rheumatology (CRD42021258712). PROSPERO: International prospective register of systematic reviews. York (GB): University of York Centre for Reviews and Dissemination; 2021: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258712. Accessed 2022 Jul 29.

20.Enablers for virtual visits. (CADTH policy insights). Ottawa (ON): CADTH; 2020: https://www.cadth.ca/sites/default/files/covid-19/cy0006-enablers-for-virtual-visits.pdf. Accessed 2022 Jul 06.

21.Gunn H, Wright MD. Telehealth-delivered supervised consumption services: clinical effectiveness, cost-effectiveness, and guidelines. (CADTH reference list). Ottawa (ON): CADTH; 2020: https://www.cadth.ca/sites/default/files/pdf/htis/2020/RA1131%20Telehealth%20Consumption%20Services%20Final.pdf. Accessed 2022 Jul 06.

22.Gunn H, Argάez C, Walter M, Loshak H. Virtual health care for adults with schizophrenia and/or psychosis: clinical effectiveness and guidelines. (CADTH reference list). Ottawa (ON): CADTH; 2020: https://www.cadth.ca/sites/default/files/pdf/htis/2020/RA1136%20Virtual%20Care%20for%20Schizophrenia%20and%20Psychosis%20Final.pdf. Accessed 2022 Jul 06.

23.Gray C, Mason J, Loshak H. An overview of direct-to-patient virtual visits in Canada. Can J Health Technol. 2021;1(6). https://www.cadth.ca/sites/default/files/hs-eh/EH0091%20Virtual%20Visits%20Final.pdf. Accessed 2022 Jul 06.

24.Jones S. A virtual waiting room? Technologies that limit contact while maintaining patient flow in medical practice settings. (CADTH health technology update). Ottawa (ON): CADTH; 2020: https://www.cadth.ca/sites/default/files/hs-eh/en0019-topic1.pdf. Accessed 2022 Jul 06.

25.Marchand DK, Visintini S. Remote presence versus videoconference technologies for the delivery of health services: clinical effectiveness, cost-effectiveness, and guidelines. (CADTH reference list). Ottawa (ON): CADTH; 2018: https://www.cadth.ca/sites/default/files/pdf/htis/2018/RA0969%20Remote%20Presence%20Technologies%20Final.pdf. Accessed 2022 Jul 06.

26.Evidence on digital health. (CADTH evidence bundles). Ottawa (ON): CADTH: https://www.cadth.ca/digital-health. Accessed 2022 Jul 06.

27.Santos C, Ryce A. Virtual clinical assessments for adults with back pain. (CADTH reference list). Ottawa (ON): CADTH; 2022: https://www.cadth.ca/sites/default/files/pdf/htis/2022/RA1219%20Virtual%20Assessments%20for%20Back%20pain%20Final.pdf. Accessed 2022 Jul 29.

28.Khangura SD, Severn M. Virtual oncology visits. (CADTH reference list: summary of abstracts). Ottawa (ON): CADTH; 2022: https://www.cadth.ca/sites/default/files/pdf/htis/2022/RB1618Virtual-Oncology-Visits-Final.pdf. Accessed 2022 Jul 29.

29.COSA Teleoncology Guidelines Working Group. Clinical practice guidelines for teleoncology. Sydney (AU): Clinical Oncological Society of Australia; 2016: https://wiki.cancer.org.au/australia/COSA:Teleoncology. Accessed 2022 Jul 29.

30.National Institute for Health and Care Excellence. COVID-19 rapid guideline: delivery of systemic anticancer treatments. (NICE guideline NG161) 2021; https://www.nice.org.uk/guidance/ng161. Accessed 2022 Jul 29.

Appendix 1: Selection of Included Studies

Figure 1: Selection of Included Studies

Appendix 3: Critical Appraisal of Included Publications

Note that this appendix has not been copy-edited.

Table 3: Strengths and Limitations of Guidelines Using AGREE II¹²

AGREE II = Appraisal of Guidelines for Research and Evaluation II; APLAR = Asia Pacific League of Associations for Rheumatology; ArLAR = Arab League of Associations for Rheumatology; ASCO = American Society of Clinical Oncology; Canadian Stroke = Canadian Stroke Best Practice Recommendations.

Appendix 4: Main Study Findings and Authors’ Conclusions

Note that this appendix has not been copy-edited.

Table 4: Summary of Recommendations in Included Guidelines

APLAR = Asia Pacific League of Associations for Rheumatology; APP = advanced practice providers; ArLAR = Arab League of Associations for Rheumatology; ASCO = American Society of Clinical Oncology; Canadian Stroke = Canadian Stroke Best Practice Recommendations; CDSS = clinical decision support system; CT = computed tomography; CTA = computed tomography angiography; MCC = multidisciplinary cancer conferences; MDT = multidisciplinary team; N/A = not applicable; NIHSS = National Institute of Health Stroke Scale; NR = not reported; TCC = targeted client communication; tPA = tissue plasminogen activator.

^aGrading of evidence: For APLAR,¹⁴ the quality of evidence was assessed using GRADE, ranging from A (high quality of evidence) to D (very low quality of evidence). For APLAR¹⁴ and ArLAR,¹⁶ the levels of evidence were assessed using the Oxford Centre for Evidence-Based Medicine scale from 1 (systematic review of randomized trials) to 5 (mechanism-based reasoning). For WHO,¹⁸ authors assessed the certainty of evidence using GRADE, ranging from “very low” to “low” to “moderate” to “high”. For Canadian Stroke,¹⁵ authors assessed the level of evidence as A, B, or C where A = Evidence from a meta-analysis of randomized controlled trials or consistent findings from 2 or more randomized controlled trials; B = Evidence from a single randomized controlled trial or consistent findings from 2 or more well-designed non-randomized and/or noncontrolled trials and large observational studies; and C = Writing group consensus and/or supported by limited research evidence.

Appendix 5: References of Potential Interest

Note that this appendix has not been copy-edited.

Previous CADTH Reports

Khangura SD, Severn M. Virtual oncology visits. (CADTH reference list: summary of abstracts). Ottawa (ON): CADTH; 2022: https://www.cadth.ca/sites/default/files/pdf/htis/2022/RB1618Virtual-Oncology-Visits-Final.pdf. Accessed 2022 Jul 28.

Santos C, Ryce A. Virtual clinical assessments for adults with back pain. (CADTH reference list). Ottawa (ON): CADTH; 2022: https://www.cadth.ca/sites/default/files/pdf/htis/2022/RA1219%20Virtual%20Assessments%20for%20Back%20pain%20Final.pdf. Accessed 2022 Jul 28.

Hui D, Dolcine B, Loshak H. Approaches to evaluations of virtual care in primary care. Can J Health Technol. 2022;2(1). https://www.cadth.ca/sites/default/files/ES/ES0358%20Evaluations%20of%20virtual%20care-Final.pdf. Accessed 2022 Jul 06.

Gray C, Mason J, Loshak H. An overview of direct-to-patient virtual visits in Canada. Can J Health Technol. 2021;1(6). https://www.cadth.ca/sites/default/files/hs-eh/EH0091%20Virtual%20Visits%20Final.pdf. Accessed 2022 Jul 06.

Enablers for virtual visits. (CADTH policy insights). Ottawa (ON): CADTH; 2020: https://www.cadth.ca/sites/default/files/covid-19/cy0006-enablers-for-virtual-visits.pdf. Accessed 2022 Jul 06.

Evidence on digital health. (CADTH evidence bundles). Ottawa (ON): CADTH: https://www.cadth.ca/digital-health. Accessed 2022 Jul 06.

Review Articles

Primary Care

Omboni S Omboni S, Padwal RS, Alessa T, et al. The worldwide impact of telemedicine during COVID-19: current evidence and recommendations for the future. Connect Health. Jan 4 2022;1:7-35. PubMed

Musculoskeletal Specialties

Gottlieb AB, Wells AF, Merola JF. Telemedicine and psoriatic arthritis: best practices and considerations for dermatologists and rheumatologists. Clin Rheumatol. May 2022;41(5):1271-1283. PubMed

Other

Anvari S, Neumark S, Jangra R, Sandre A, Pasumarthi K, Xenodemetropoulos T. Best Practices for the Provision of Virtual Care: A Systematic Review of Current Guidelines. Telemed J E Health. May 9 2022. PubMed

Additional Publications That Did Not Meet Eligibility Criteria of This Report

Additional references of interest, for guidelines without a systematic literature review or for best practice guidelines and consensus statements, are provided below. Separate lists are provided for primary care (including a summary and table of recommendations), musculoskeletal specialties (including a summary and table of recommendations), and other specialities (a reference list only).

Primary Care

The study designs included in these articles were practice guidelines and consensus-based guidelines. In total, 12 articles covered topics regarding the use of telemedicine in primary care. The majority of them were best practice guidelines developed by different organizations. Eleven out of 12 articles were published in the context of the COVID-19 pandemic. Nine articles were developed by Canadian researchers/organizations, thereby increasing the relevance and generalizability to the Canadian population. Common themes included: the potential for virtual visits and different forms of telemedicine to be appropriate for a variety of medical visits; the need for adequate patient and physician preparation to ensure the virtual visit is optimized; ensuring that regular medical compliances such as privacy to information is adhered to; the potential for virtual visits to reach more patients than possible with physical visits; patient consent; and documentation. Each article is listed below, with corresponding recommendations in Table 5.

Furlepa K, Tenderenda A, Kozlowski R, Marczak M, Wierzba W, Sliwczynski A. Recommendations for the Development of Telemedicine in Poland Based on the Analysis of Barriers and Selected Telemedicine Solutions. Int J Environ Res Public Health. Jan 22 2022;19(3):1221. PubMed

Virtual health handbook for PHSA staff. Vancouver (BC): Provincial Health Services Authority; 2022: http://www.phsa.ca/health-professionals-site/Documents/Office%20of%20Virtual%20Health/Virtual%20Health%20Handbook.pdf. Accessed 2022 Jul 17.

Telemedicine and virtual care guidelines (and other clinical resources for COVID-19). Ottawa (ON): Royal College of Physicians and Surgeons of Canada; 2020: https://www.royalcollege.ca/rcsite/documents/about/covid-19-resources-telemedicine-virtual-care-e. Accessed 2022 Jul 17.

UHN Virtual Care Clinical Advisory Panel. Clinical Guiding Principles for Virtual Care. (Virtual care: a healthier world is within our reach). Toronto (ON): University Health Network (UHN); 2022: https://www.uhn.ca/corporate/AboutUHN/Virtual_Care/Documents/Clinical-Guiding-Principles-Virtual-Care.pdf. Accessed 2022 Jul 17.

Ong MK, Pfeffer M, Mullur RS. Telemedicine for adults. In: Post TW, ed. UpToDate. Waltham (MA): UpToDate; 2022: www.uptodate.com. Accessed 2022 Jun 13.

COVID-19 toolkit: virtual care. Considerations for patients, health professionals and digital teams involved in Virtual Health. Ottawa (ON): Accreditation Canada; 2020: https://sharedhealthmb.ca/files/covid-19-virtual-care-toolkit.pdf. Accessed 2022 Jul 17

Virtual care best practices guide. Ottawa (ON): University of Ottawa; 2020: https://med.uottawa.ca/family/sites/med.uottawa.ca.family/files/virtual_care_best_practices_guide_-_en_-_april_3_2020.pdf. Accessed 2022 Jul 18.

Getting started with virtual care. Everything you need to know to provide synchronous virtual care. Dartmouth (NS): Doctors Nova Scotia; 2020: https://doctorsns.com/sites/default/files/2020-06/toolkit-virtual-care-v2.pdf. Accessed 2022 Jul 17.

Adopting and integrating virtual visits into care: draft clinical guidance for health care providers in Ontario. Toronto (ON): Ontario Health; 2020: https://quorum.hqontario.ca/Portals/0/Users/170/54/10154/Draft%20Clinical%20Guidance_Adopting%20and%20integrating%20virtual%20visits%20into%20care_V1.pdf?ver=2020-03-13-091936-370. Accessed 2022 Jul 17.

Prasad A, Brewster R, Rajasekaran D, Rajasekaran K. Preparing for telemedicine visits: guidelines and setup. Front Med (Lausanne). 2020;7:600794. PubMed

Providing geriatric virtual care across the South West: guidance document for health care and community support services providers. London (ON): South West Frail Senior Strategy; 2020: https://www.sjhc.london.on.ca/sites/default/files/documents/2020-12/guidance_document_-_providing_geriatric_virtual_care_across_the_sw-12.15.20.pdf. Accessed 2022 Jul 18.

Advice to the profession: virtual care. Toronto (ON): College of Physicians and Surgeons of Ontario: https://www.cpso.on.ca/en/Physicians/Policies-Guidance/Policies/Virtual-Care/Advice-to-the-Profession-Virtual-Care. Accessed 2022 Jul 17.

Musculoskeletal Specialties

Two articles were found covering musculoskeletal topics: 1 consensus-based guideline and 1 practice guideline. Wahezi et al., 2020 reported on a reference guide for musculoskeletal and neurologic examination that can be used in telemedicine practice. Barber et al., 2022, who included a rapid literature review and a subsequent Delphi process, reported on quality and patient safety considerations when developing the best practice statements for rheumatology virtual care. The common themes identified in both articles were that virtual care can be appropriate to assess certain musculoskeletal conditions; physicians/clinicians should adhere to national recommendations on best practices, provincial standards, and regulations for virtual care; and, where appropriate, patient-reported outcomes that help direct approaches for care should be used during virtual encounters. Each article is listed below, with corresponding recommendations listed in Table 5 in Appendix 6.

Barber CEH, Levy DM, Ahluwalia V, et al. Best practices for virtual care: a consensus statement from the Canadian Rheumatology Association. J Rheumatol. Apr 2022;49(4):408-418. PubMed

Wahezi SE, Duarte RA, Yerra S, et al. Telemedicine during COVID-19 and beyond: a practical guide and best practices multidisciplinary approach for the orthopedic and neurologic pain physical examination. Pain Physician. Aug 2020;23(4S):S205-S238. PubMed

Other Specialties: Consensus Statements and Guidelines

Marino LV, Collaco NC, Ashton JJ, et al. Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus. Clin Nutr. Mar 2022;41(3):661-672. PubMed

Puts M, Papadopoulos E, Brennenstuhl S, et al. The development of geriatric assessment and intervention guidelines for an online geriatric assessment tool: a Canadian modified Delphi panel study. Curr Oncol. Feb 4 2022;29(2):853-868. PubMed

Ben-Arye E, Paller CJ, Lopez AM, et al. The Society for Integrative Oncology Practice recommendations for online consultation and treatment during the COVID-19 pandemic. Support Care Cancer. Oct 2021;29(10):6155-6165. PubMed

Couturier J, Pellegrini D, Miller C, et al. The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond. J Eat Disord. Apr 16 2021;9(1):46. PubMed

Cremers HP, Theunissen L, Hiddink J, et al. Successful implementation of ehealth interventions in healthcare: Development of an ehealth implementation guideline. Health Serv Manage Res. Nov 2021;34(4):269-278. PubMed

Qureshi AZ, Ullah S, Aldajani AA, et al. Telerehabilitation guidelines in Saudi Arabia. Telemed J E Health. Oct 2021;27(10):1087-1098. PubMed

Stipa G, Gabbrielli F, Rabbito C, et al. The Italian technical/administrative recommendations for telemedicine in clinical neurophysiology. Neurol Sci. May 2021;42(5):1923-1931. PubMed

Other Specialties: Practice Guidelines and Recommendations

Virtual care in Canada: strengthening data and information. Ottawa (ON): Canadian Institute for Health Information; 2022: https://www.cihi.ca/sites/default/files/document/virtual-care-in-canada-strengthening-data-information-report-en.pdf. Accessed 2022 Jul 19.

Deda LC, Goldberg RH, Jamerson TA, Lee I, Tejasvi T. Dermoscopy practice guidelines for use in telemedicine. NPJ Digit Med. Apr 27 2022;5(1):55. PubMed

Cancer Care Ontario. Person-centred virtual cancer care clinical guidance. 2022; https://www.cancercareontario.ca/en/guidelines-advice/types-of-cancer/69581. Accessed 2022 Jul 19.

Adopting e-health solutions: implementation strategies. Best practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario; 2017: https://rnao.ca/sites/rnao-ca/files/bpg/Adopting_eHealth_Solutions_WEB_FINAL.pdf. Accessed 2022 Jul 19.

Venkatesh U, Aravind GP, Velmurugan AA. Telemedicine practice guidelines in India: Global implications in the wake of the COVID-19 pandemic. World Med Health Policy. 2022. PubMed

Privacy and security considerations for virtual health care visits. Guidelines for the health sector. Toronto (ON): Information and Privacy Commissioner of Ontario; 2021: https://www.ipc.on.ca/wp-content/uploads/2021/02/virtual-health-care-visits.pdf. Accessed 2022 Jul 19.

Sarveswaran G, Rangamani S, Ghosh A, et al. Management of diabetes mellitus through teleconsultation during COVID-19 and similar scenarios - Guidelines from Indian Council of Medical Research (ICMR) expert group. Diabetes Metab Syndr. 2021;15(5):102242. PubMed

Sharma VD, Safarpour D, Mehta SH, et al. Telemedicine and deep brain stimulation - current practices and recommendations. Parkinsonism Relat Disord. 2021;89:199-205. PubMed

Thai-Van H, Bakhos D, Bouccara D, et al. Telemedicine in audiology. Best practice recommendations from the French Society of Audiology (SFA) and the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL). Eur Ann Otorhinolaryngol Head Neck Dis. 2021;138(5):363-375. PubMed

Gómez Rivas J, Rodríguez-Serrano A, Loeb S, et al. Telemedicine and smart working: Spanish adaptation of the European Association of Urology recommendations. Actas Urol Esp (Engl Ed). 2020;44(10):644-652. PubMed

Horton MB, Brady CJ, Cavallerano J, et al. Practice guidelines for ocular telehealth-diabetic retinopathy, third edition. Telemed J E Health. 2020;26(4):495-543. PubMed: PM32209018

Rodriguez Socarrás M, Loeb S, Teoh JY, et al. Telemedicine and smart working: recommendations of the European Association of Urology. Eur Urol. 2020;78(6):812-819. PubMed

Virtual care guidelines for clinicians. Toronto (ON): Holland Bloorview Kids Rehabilitation Hospital; 2020: https://hollandbloorview.ca/sites/default/files/2020-05/HB-VirtualCareGuidelines-May20.pdf. Accessed 2022 Jul 19.

Virtual visit guide for midwives. Toronto (ON): Association of Ontario Midwives; 2020: https://www.ontariomidwives.ca/sites/default/files/2020%2004%2006%20Virtual%20Visits%20Guidance%20for%20Midwives%20-%202020.pdf. Accessed 2022 Jul 19.

Lopes M, Oliveira GMM, Ribeiro ALP, et al. Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology - 2019. Arq Bras Cardiol. 2019;113(5):1006-1056. PubMed

Myers K, Nelson EL, Rabinowitz T, et al. American Telemedicine Association practice guidelines for telemental health with children and adolescents. Telemed J E Health. 2017;23(10):779-804. PubMed

Appendix 6: Recommendations Related to Musculoskeletal Topics

Two articles were found covering musculoskeletal topics: 1 consensus-based guideline and 1 practice guideline. Wahezi et al., 2020 reported on a reference guide for musculoskeletal and neurologic examination that can be used in telemedicine practice. Barber et al., 2022, who included a rapid literature review and a subsequent Delphi process, reported on quality and patient safety considerations when developing the best practice statements for rheumatology virtual care. The recommendations from those articles are listed in Table 5.

Table 5: Summary of Recommendations in Documents of Potential Interest

ID = identity; OTN = Ontario Telemedicine Network.