How safe is virtual healthcare?

virtual models of care, digital health, patient safety, equity, healthcare quality

Background

Undeniable opportunities are posed by virtual models of care that address long-standing health system sustainability challenges and improve access. Virtual models of care describe preventive, diagnostic and treatment practices without face-to-face contact with healthcare providers. Common forms of virtual care that have rapidly progressed due to the coronavirus disease 2019 (COVID-19) pandemic include health provision via telephone or video-conferencing software, the use of wearable monitoring devices, digitized health information and remote (in-home) monitoring [1].

Virtual care has created healthcare contexts with further complexity as a result of novel care settings and technological systems that require different models and processes of care [2]. There may also be greater presence of family members, members of the public and technical support staff during healthcare encounters. These components collectively create highly unpredictable care environments. We examine the key risk areas of virtual healthcare for patient safety based on emerging evidence.

Evaluations of virtual models deployed internationally indicate that their key risks relate to retaining the confidentiality of highly personal or sensitive information and ensuring equitable access to services with the necessary supports. Such risks are particularly pertinent to individuals who experience existing health inequities; those with complex health and social needs, low health literacy or from low-income backgrounds [3, 4]. Whilst there has been much scrutiny of the safety features of digital health tools [5], exploration of patient safety in virtual healthcare through an equity lens is needed to ensure quality.

Safe environment for healthcare encounters

Virtual models of care can remove geographic and travel constraints to increase equity in access to care, in addition to creating efficiencies for health systems, patients and carers. Yet, traditional clinical contexts have been devised to optimize safety in care delivery not only through service design and infrastructure planning but also through socializing healthcare staff to their clinical workspaces [6]. Systems engineering based on human factors principles has underpinned more than 20 years of healthcare improvement work to create physical spaces and workflows that reduce potential for risk and error [6]. Outside of these carefully devised physical contexts, further risks and unknowns are introduced through the use of virtual models, which may impact patient safety [7].

Identified patient safety risks include lack of transparency between patients and professionals with regard to the individuals who are present in a healthcare encounter, which may include other healthcare staff situated in shared spaces or others within the patient’s home or public places [1]. Such interactions have propensity for breaches in the confidentiality of patient and health provider information, which may disproportionately affect those from low socio-economic backgrounds.

Equity in service access

Evaluative evidence identifies several populations for whom increased access and efficiency to care have resulted from virtual models, such as those in remote geographic locations, those who are constrained by work or caring commitments and those managing multiple conditions who have good health literacy [1]. But access to virtual healthcare is not equitable, with associated risks to the safety and quality of care. Health and care inequities are exacerbated when virtual care is not accessible to population groups who require additional support to access and/or engage in healthcare encounters.

Affected population groups include those who require language translation, for whom technologies are not consistently available (e.g. for people living remotely or from low-income backgrounds) or those with complex psychological health or social needs [8]. Key risks of poor quality virtual care relate to having poor internet connectivity, resulting in service or data loss, and to the degree of comfort and trust individuals have in accessing care virtually. Health literacy is therefore a critical underpinning factor in the equitable service quality. Reports highlight the value of family member and/or carer contributions to address these gaps by gathering patient data, providing interpersonal or technical support, or providing relevant health and social information during virtual care consultations [9]. Such supports are not consistently available for service users; determining the level of support required for an individual to utilize virtual care safely and its availability is an essential step. Addressing issues of equity on virtual care quality requires dedicated, long-term, resourcing required to mitigate reliance on family and carer support.

Boundaries of clinical governance and gaps in current models

Emerging evidence from virtual care models that have been adopted and/or expanded due to the COVID-19 pandemic points to the boundaries of current models of clinical governance and the need for their expansion to address the new horizon of widespread integrated virtual models. Creating safety in hybrid systems that integrate virtual and face-to-face models will require the evaluation of current systems engineering and the de-implementation of practices that do not support safety in such contexts [7]. Models and resources from safety science and quality improvement literature provide a framework for exploring the novel risks created by virtual models and redesigning or repurposing healthcare processes and physical spaces to integrate virtual care [7]. Harnessing these existing frameworks and applying an equity lens in this process may support us to consider how virtual care environments, interpersonal interactions and the supporting technologies can be optimized for all service users. Inclusive design principles and co-creation of virtual care models provide opportunities to gain insight from service users, address issues of equity, mitigate unintended safety and quality risks resulting from the integration of virtual models and ensure that the necessary supports are in place [8, 10].