Digital Determinants of Health: Expanding Healthcare Access for Marginalized and Isolated Populations Using Virtual Technologies

According to the Canadian Radio-television and Telecommunications Commission (CRTC), almost 88% of  Canadians have access to a high-speed broadband internet connection, compared to just over 45% for rural communities. This has led to concerns around a digital divide, the broader digital determinants of health, and whether telehealth technologies can actually be delivered without widening health disparities. In this episode of the Public Health Insight Podcast, Dr. Keith Thompson, Chief Medical Officer of iTelemed Canada, remains with us to discuss the importance of addressing the digital determinants of health and the ways in which telehealth can be leveraged to reach marginalized and isolated populations.

Podcast Guests

• Dr. Keith Thompson

Podcast Hosts

• Gordon Thane, BMSc, MPH, PMP®
• Leshawn Benedict, MPH, MSc, PMP®

References for Our Discussion 

• Canadian Medical Association: Virtual Care in Canada - Discussion Paper
• The Agenda with Steve Paikin: Is Virtual Health Care Here to Stay?
• American Medical Association (AMA): A review of telehealth trends: Informing the future of virtual care
• Canadian Radio-television and Telecommunications Commission (CRTC) BROADBAND FUND Closing the digital divide in Canada

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Music Credits

The following tracks used in this episode were all produced by Lukrembo:

• Daily • Bread • Biscuit • Bored • Chocolate • Onion • Holiday

Transcript

Dr. Keith Thompson: 0:00

I think from the public standpoint, I'll say, yes. Uh, I'm old enough to remember standing in line at the bank, waiting to take money out and waiting to pay my bills with a teller and stamp right now, just doing this ATM. No, I do it at home on my phone. Right? Like how crazy is that? Uh, who wants to go back to that old method? So I think if you asked the patients and they would say, oh, seriously, I got to come to your office

Sully: 0:24

This is the public health insight podcast.

Ben: 0:28

Before we move on is important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with.

Sully: 0:36

In the previous episode, Borden and Leshaun spoke with Dr. Keith Thompson, chief medical officer of Canada, about virtual healthcare technologies and how the pandemic has influenced healthcare policy. And the uptake of telemedicine services in the second part of the discussion, Dr. Thompson remains with us to discuss the importance of addressing that there's still determinants of health and the ways in which tele-health can be leveraged to reach marginalized and isolated populations. This is where they left off.

Gordon: 1:09

And speaking of barriers, according to, uh, the Canadian radio television telecommunications commission. We know that almost 88% of Canadians have access to high-speed broadband internet connection. So that's really good. However, compared to just 45% of rural communities, so this brings up concerns and questions around a concern of the digital divide that you spoke on. When we just started this conversation, the broader digital determinants of health, if you will, and whether these virtual health technologies can actually be used, uh, to deliver care without, widening the disparities even further. So I'm just going to ask you, um, it's a mouthful there, but I'll put it out to you. So we talked about a lot of problems that virtual care can help to solve, but what are some problems that it does not help to solve as easily?

Dr. Keith Thompson: 2:00

Yeah, that, you know, and listen, you hit the sweet spot on this because we can run a line to the community and we can improve connectivity. But, you know, there are lots of studies that would say access to care, whether it's virtual or face-to-face is only what 25 and some studies as low as 10% in the U S determining healthy outcomes there, you're getting into what are the social determinants? Why is there poor health? You know, and it's it's poverty or it's environmental, it's social support, it's education, it's literacy. There's so many other things. Uh, it's culture, it's genders, genetics. Uh, I mean, I'm looking at the list ahead of me. There's like 12 items, right? The classic social determines, you know, them better than.

Gordon: 2:43

Yeah.

Dr. Keith Thompson: 2:44

But, uh, digital and virtual may not address all of those, uh, or access to care. It's a platform to get into the community to provide care. But it's got to go beyond that I think is a challenge. And you know, there are some regions that are doing a wonderful job at that. Uh, and some other countries actually, the way they've kind of cracked code on this is, uh, looking and learning that the physician need not. Doctor do it all or the primary go-to. So they've leveraged health technicians. And in India, there's a program where with a knapsack and a carry case for ultrasound and weigh scale and a little digital device, uh, can go into these communities and using the cell network, uh, and do those encounters, uh, with patients and really, uh, provide a lot of care, uh, that can D can't off, right. And not necessarily need physician engagement. So I think that that's the first part. Second part is a look at a program by, uh, and again, no financial conflict of interest, but Phillips has done some wonderful work around access to care or community life center. And so it means going to the community and just like any other innovation and society, what are your needs customer survey? And what we need is kind of micro economies around this. So Phillips went in recognizing that clean water and power with first thing, set up a solar panel. Set up clean water there's becomes your health station, but that station, when it's not serving health needs and the evening, there's a light for the soccer field. It's a center where people can come and chat and gathering. It's a gathering place it's safe. Right. And they know that, uh, you know, the community services and maybe it's a whatever, a social dinner or it's a party or whatever, right. Or it's an educational experience. A group of women get together. Maybe there's a micro economy. That's evolved because they need power to run, you know, whatever device. So I think we think outside the box that healthcare is not the sole solution, but what connections we bring in to those communities, how we can build around that really is I think what we need to start to think about.

Leshawn: 4:58

Yeah. And w when we were talking about the social determinants of health, which is what all this is, encompassing, making sure that we touch on those social factors that affect health there's so many. And one of the things that were striking to me is that I'm talking about the lack of inter-operability or connectivity with ER, EMR or, electronic medical records, E booking and lab diagnosis. So like there, there seems to be a lack of collection with the social determinants of health data within these databases itself. And so, what are your thoughts on

Dr. Keith Thompson: 5:30

Yeah. I, I would reference Dr. Dan Peppa. Who's a great lead here in our community, on the digital and anterial health, uh, uh, team network. And, uh, I say, Dan, I'm a convert to, uh, coding. Right. And he said, Keith, I've learned not to boil the ocean. Uh, basically that we got it. Find the patients that are need and the codes. And, you know, what's interesting is what are the ICD I hate to say we're still using ICD nine because that's what deal have codes require, so Uh, I think it stands for international a disease registry.

Gordon: 6:04

of disease.

Dr. Keith Thompson: 6:05

Thank you. There you go. So ICD nine, ICD 10 was, are we do an ICD 11 yet or, yeah. Uh, but much more descriptive, but bottom line, as Stan would say, let's not boil the ocean. Let's just get good coding practices, uh, within primary care. And what are the codes for social determinants? And, uh, you know, is that going to be seen as acceptable or intrusive? So if I code you for opiate use disorder or, uh, extreme poverty, right? Uh, is that marginalizing you further within your medical records? So when I go to a specialist and the first thing that pops up, right. Do I necessarily want to share that? I mean, th these are some of the ethical consideration drought, but in a pure population health, I agree. We don't know. And that's probably assuming as well, there are many patients out there that aren't even connected. Right. They, they have no PR like a lot of these surveys I'm sure are upon people who have primary care, they're already attached, but what will the ones that are right. and what is their need certainly, uh, around, uh, uh, healthcare, let alone I'm sure. Health care may not be the first thing on their mind. Their first thing may be thinking about where's the next meal coming from. So,

Gordon: 7:25

Oh boy. and we've had episodes on the pros and cons, if you will, about collecting race and ethnic based data. And it's not clear cut either way that who owns the data. If it falls into the wrong hands, you can marginalize populations even further social exclusion. So there has to be a framework, even from a policy level governing how it is that it can be used.

Dr. Keith Thompson: 7:47

Well, I was just going to say, you know, like a code for, uh, many people living within one small dwelling, right. Might be a code that we'd recognize for future pandemics, regardless of social status or income or any of that. I have five people in one household, right. That's a risk. And we see again how hard it was hit and racialized communities, uh, for COVID. And, and part of the reason for that was you're right. Many people, right. Uh, into one small apartment, uh, to e-coat and existence, uh, but high risk rate for transmission of the disease. Uh, not to mention that they can't afford to take sick time and yeah, we can go on to that discussion, uh, as well,

Gordon: 8:26

Sorted to dig further and not though. So because of physicians and healthcare providers, scope of practice. For example, if someone's in a precarious housing situation it's essentially out of a physician scope to maybe necessarily directly be involved in getting that individual to a better situation. Do you think that's maybe why there's a disconnect with that information be collected in, in terms of EMR?

Dr. Keith Thompson: 8:48

Yeah. I mean, there are some wonderful tools that were created, right? The, the poverty screening tool, and we're really being encouraged, right. To ask and see, there may be some programs that people are not aware of, that they're eligible for OD GSP or they're eligible for CPP or whatever. And we can help them with that. Uh, we might not all know all the ins and outs of the application, but we certainly can steer them in the right, uh, the right way. So, uh, maybe, you know, again, having that relationship and part of a thorough history in primary care, I think we do a pretty good job of understanding where our patients come from or understanding their story. Right. Uh, I know them in, in, in detail, uh, that's the danger with virtual is that it's episode and maybe they have access to a physician, but do I really understand on a one or two. Time visit for say a drug refill or medication refill. Do I know their whole history and they have time to delve into it. Right? And so this is I think, where the challenge lies, uh, is getting everyone connected in some manner to primary care face-to-face or virtual, I think, uh, is beside the point getting them into primary care. And once that is established in that relationship as longitudinal, then the value add may be if they want to talk to me by telephone for certain things. That's okay. Right. Uh, so I think yeah, the issue that the technology can't solve is getting people outside the lifeboat, still floating in the water into a primary care, a raft, right. Uh, that that's

Leshawn: 10:32

No for sure. And another thing that brings to mind for me is the idea of, you know, traditionally these physicians are used to having these physical one-on-one interactions in person. Now there's been that transition to that online environment and then there's something called a website manner. So how does that kind of play into this.

Dr. Keith Thompson: 10:51

Yeah. So the website, man, I love that term. I think it was coined during the, uh, CMA, their virtual care task force, or it may have come from the U S I think the root of it. And it really just centers around, uh, patient centered care. Right. So, as I'm talking to you, I'm looking at the camera, I'm engaged. I'm not doing this.

Gordon: 11:11

Okay.

Dr. Keith Thompson: 11:11

What was your heart rate the other day? All right. Just anyhow. So it, that the patient knows you're there and you're engaged and, and they can sense that. I think video is a value add. So certainly is it's a, another layer to that engagement, for sure. It helps. And you know, certain things like privacy, right. Uh, and so amazing. I think you've heard on other podcasts, a patient, like, are you able to yeah. I'm at the Tim Horton's doc. It's okay, go ahead. Right. Yeah. You sure you okay to talk now about this problem in line? Yeah. Uh, some patients don't want others that were my own. Just a sec. I got to step up. There was an interesting comment. I remembered by one, uh, employer, uh, and this is again pre COVID, where they were looking to provide, uh, virtual care for their employees to save them, having know simple stuff. They need a drug refill, whatever to leave time, leave work. Hey, we'll provide that service. We have physicians on call who provide, uh, your needs and they dedicated a separate room and it was private and quiet, but it was interesting that as soon as you went to the. Nice job going to the room. Who's he talking to what? Hey, what's wrong. John's right. And they knew that was the doctor's room. Right. So privacy was kind of shot. So a website manner, I think though just entails the relationship with a patient. Right. Just being on best behavior, not wearing your Ron, John, uh, shirt, although maybe it's okay.

Gordon: 12:31

Awesome. So just to bring things back, full circle we know you had mentioned you're a part of this working group with the I E E S a I'm working to recommend standards in terms of increasing digital health access for rural, and remote communities. So what are, what do those standards look like? And do any of them involve addressing these digital terms of health that we spoke about?

Dr. Keith Thompson: 12:56

Yeah, they, they certainly, they're hoping to go that way. So very early in this working group, uh, I just learned this past week, one of the official standards. So to define this working group, we're proposing ideas and standards. The first one's going to be definitions the lexicon, uh, right. The verbiage of virtual care. We'll write a document and we'll elevate it. And if it's accepted the standards, Hey, great. Uh, one of the standards already being worked on, uh, P 27 95, which is looking to understand regionally, uh, dedicated lines or pathways for health care. And what I learned from that group is what's been interesting in some of the areas, the capacity, the bandwidth is great, but because everyone's at home on Netflix, it's chewing up bandwidth. So when they need it for the local hospital, right to hook into the ICU, or they need data, It's glitching. The Wi-Fi like, you know, at home and kind of got five people on their device and the wifi. Same sort of problem with healthcare. So that's one issue related to kind of looking at first is a dedicated line. Uh, and also they've done some early mapping. Uh, I think you guys love gifs maps, right? It take population health and put it on a mouse. So they've done healthcare access and they have done connectivity. And I'm not sure that the finding, I think it's, uh, just cell phone connectivity at this point and just plot it out. And of course you can see right, the hot regions being the urban and kind of thin zone and opaque as you get into those worlds. And so trying to figure out how do we solve that issue in connectivity. And is it cell phone lines? Uh, is it satellite connectivity? I mean, is Elon Musk going to save us all when the issue of connectivity? I don't know, but just on that note, as you get to the very Northern regions of, uh, of Canada, uh, It doesn't work and there's maybe only a hundred to 200,000 people within that region, mostly indigenous. And nobody cares about that market. Cause it's not big enough. There's no sustainable business model. Right. And so there again, the issues and marginalization and remote regions is how do you sustain, what is the business model around this? And so, uh, we're looking at very early on how we might be able to connect the reduce greenhouse gas emissions, uh, as a value add. And can we create some sort of social or developmental impact bond, uh, that would sustain that, uh, make that a model that goes beyond just the government throwing money at it, or a philanthropy or NGO support. Cause the problem is that eventually the plug gets pulled on those revenues and you're done. Right. So how might you build a sustaining. Business model or economy around that. And I think if there's a way to connect green, uh, you know, uh, reduce gas emissions, cause think about virtual, definitely less travel, especially Northern regions. Oh my gosh. To fly somebody, uh, you know, south, uh, to connect or transport them, plus the family having to come. And the indirect costs of getting a motel room to stay with mom or dad or their loved one while they're in hospital. If you add that all up, it's a substantial savings in terms of reduced greenhouse gas. Um, how you structured in a social impact bond is extremely challenging. These bonds are complicated. They take tons of time. Zenna kayak is, uh, I will call her my hero right now because she understands this very well. Uh, and she's done a lot of work on this. And, uh, in our last session we were chatting in, Zaida said, Keith, you know, the work that goes into creating these bonds really is almost unnecessary. If a government agencies, the patient. And you want to just go directly to a provider and say, here's the outcome we're offering or we'll pay for. And if you can provide that outcome, here's what, here's, how we'll fund it. So anyways, that's so I Tripoli believe it or not is, is looking at this potentially, but very, very early on right now. It's all about the connectivity and how to get it equitable across regions.

Gordon: 17:07

All right. So those are very interesting points. I wasn't aware of the climate change angle. I didn't really conceptualize it that way. So that's a very, um, in terms of stating the value add of virtual care, I think that's a very critical component. So I want to talk to you about in terms of a final parting thoughts in terms of this conversation. Um, is it safe to say that virtual care is here to stay, uh, in our post pandemic recovery? Uh, is the future somewhere in between, like you mentioned, where it's like a hybrid of in-person and virtual care deliveries, like, what are your thoughts?

Dr. Keith Thompson: 17:41

Yeah. I think from the public standpoint, I'll say, yes. Uh, I'm old enough to remember standing in line at the bank, waiting to take money out and waiting to pay my bills with a teller and stamp right now, just doing this ATM. No, I do it at home on my phone. Right? Like how crazy is that? Uh, who wants to go back to that old method? So I think if you asked the patients and they would say, oh, seriously, I got to come to your office to talk about my lab result. No way. I think the public pressure will be such that this has to in some manner or form be sustained going, uh, forward. Uh, one of the programs, one of the projects Dr. Bridget, Ryan is doing is that understanding that high bred model. So a combination of face-to-face and virtual, and we already have an idea of what things we can do really well virtually, uh, again, in the context of an ongoing sustained relationship. With the patient. And that's where the challenge comes for those patients outside those individuals, outside of that tent or outside of primary care, how do we make this service, uh, equitable? And I think, you know, my, my final thought on this really is going to be the, that it's more than just the technology. I think sustainability for primary or care and virtual care isn't about workflow and it's not the technology, but the adoption. Right. But when we get into the marginalized populations, uh, it's really, uh, back to those other determinants of health and there's other reasons they're marginalized. And I think those have to be addressed almost with, or at first upfront, you know, prior to, I mean, health care is great, but it's not serving the greater need in the community. Right. Or are the other reasons that people are outside that tent?

Leshawn: 19:26

totally. And that what you said about connectivity and, you know, talking about how there's other kind of determinants, not just that limited technology or connectivity, you know, you get into stuff like digital health literacy you know, their beliefs, people's beliefs about a specific, um, like tool, whether it's harmful or not. And then you get into values and cultural norms and preferences to use these technologies. And we have to keep that in the back of our minds when we're talking about all these, because people have different backgrounds that are influenced by their social surroundings and contexts. So to be able to eventually create an integrative system, you have to consider the thoughts and perspectives of everyone involved and keep in mind these digital and social determinants of health in whatever.

Gordon: 20:09

Co-create co-design.

Dr. Keith Thompson: 20:11

You know, I think what's encouraging about, uh, programs like this and honestly, is there's a trap of, and I think I heard it referenced a on CBC. I can't remember the interview, but you know, the, the social media performance and, uh, I even myself feel guilty. Talking about this and wonderful ideas and concepts, but I'm like chomping at the bit. I just want to get going right. And get started. And it's so frustrating and hard because we've done multiple grants and applications has like, just give me funding for this. I just want to do it. Right. And I think, uh, being able to talk about this as a community and network with others that are passionate about this, inspires you to keep going number one, uh, but really look for areas where you can succeed. And like again, Dr. Pepe said, you know, I'm tired of trying to boil the ocean. Let's just work on getting physicians to code better. Right. Maybe we'll get physicians to be impassioned about taking on patients that are marginalized and, uh, look at granny's, uh, determinants of six influencers of change. Right. And I think I posted that before on LinkedIn making that, which is difficult. Really what would inspire you and hearing those patients stories inspires you? So, part of what we're doing today is I think, uh, inspirational for others and motivate them to change either within their organization or put the pressure on the government for things like referred to funding for virtual house calls, right. Would be an important, not just cause of my conflict of interest, regardless of platform. This is a need right. That we could serve. And how do we increase public awareness and pressure, right? To get that organizational or structural change within the system. And then also for the individuals to be inspired and hearing those stories, you know, hopefully that's what we can do today. You know, again, there's a lot of good work out there, uh, that, you know, uh, grassroots and yeah, we need mental health access. To be honest, right now, I find within my own practice, the funding for that, it's extremely difficult. The, that the public system is backed up beyond belief, uh, and is in crisis survival mode. But to get, you know, cognitive therapy or behavioral or one-on-one psychotherapy or good mental health counseling, uh, boy, if you don't have coverage, uh, that's a challenge. I know there's a program, uh, together, all it used to be big white wall became together. All they're just pulling the plug on it seriously, no more funny. Cause it was a publicly accessed form that people could go into and they could get some sort of connection with others, right.

Gordon: 22:45

I didn't know that big white wall there's they're pulling the funding.

Dr. Keith Thompson: 22:49

It's it became together all. And, uh, one of my patients just told me about this the other day, that dockets, we just got noticed it's not being funded anymore.

Gordon: 22:58

Wow.

Dr. Keith Thompson: 22:59

Uh, so there's bounce back. Right. Which is, uh, which is, you know, it's okay. It's some telephone support. It's a workbook style. But uh, for the one-on-one stuff. Yeah. Uh, that's tough. There's not a lot out there.

Leshawn: 23:13

So when we're talking about virtual care and you kinda mentioned how to make it fit within that publicly funded system, what is the role for kind of private organizations that kind of play a role in this? Like, keep in mind if the government doesn't add funding to certain infrastructure to support this the private sector may be able to swoop in, what are your thoughts on some of that end, you know, maybe, uh, a scenario where more, um, work insurance may cover certain aspects of virtual care. Whereas the public system doesn't.

Dr. Keith Thompson: 23:43

Well, and pre COVID that's exactly what happened. I mean, that's the reason that companies like maple dialogue, Akira existed is because their employers and Teladoc, actually, I was one of the startup, uh, consultants, if you would for helping telecon get into Canada. Uh, and so that was their business model. We go to employer, you have a thousand people we'll charge you$10. Uh, for access to our physicians when there's a problem. Uh, so COVID hit and then the feet codes of course, had to be generalized and we are seeing a maple and all of those providers have private, uh, private, uh, telemedicine providers, virtual care providers, uh, be allowed to build under those COVID coats. So I think post COVID, you can already see those companies have aligned. They've applied for vendor verification. They'd been accepted. I know maple has for sure. And I think, uh, dialogue has as well, uh, that if there's a, a special rule for billing, the OHIP codes virtually, uh, they'll likely get the blessing and the go ahead. So if physicians want to use our platform, so I think there's room for sure. What, uh, you know, from a primary care perspective, one of the concerns we've had is that, okay, you know, episodic versus continuity of care, there's that constant friction between the convenience of access and the quality of the outcome when it's somebody that knows you. Long-term right. Uh, and so the danger is going to be, as you see, in a virtual walk-in renewal, renewal, renewal, diabetic, high blood pressure, without any sort of, you know, uh, long-term or episodic annual health review, what's your hemoglobin A1C and your cholesterol, the docket, the walk-in doesn't really care. Oh, you're here for your meds. Here you go. 90 days. Okay. You're good. You've got a doc. Yeah. Okay. Here you go. Right. Meanwhile, the patient has been never encountered right to review what's going on. So that I would say is the danger of having this as a, almost two tiered system. I say two tiered still publicly funded, but easily access. Uh, and I think it, ideally we want to funnel it into a primary care provider that has a relationship. And, uh, again, how do we make an incentive to look after those patients that are marginalized street medicine as a specialty unto itself? Right. I mean, I I'm, uh, a white guy in Northern London that knows nothing about dealing with, uh, you know, patients living on the street. I'll be honest and that's a whole other expertise. So I would like to learn on Dr. Andrea, Serena's done some amazing work here in London and community health center. She works at just phenomenal work. Uh,

Gordon: 26:28

we got to get her on the podcast.

Dr. Keith Thompson: 26:29

know, I was just going to say a hundred percent. I'll do the intro. Yeah.

Gordon: 26:33

Oh, awesome. So yeah. Would that being said, you presented both sides of the argument, you, you were very strong on saying, you know, virtual care in, by no means as, as we are now as the silver bullet in of itself. so given all these nuances and contexts what is your message for people in public health, healthcare, just to general citizen, uh, in terms of virtual care and advancing it forward in an equitable way.

Dr. Keith Thompson: 27:00

there's a lot in that one statement, I will say, certainly in advancing it forward, I think we have to keep our eyes on the ball of equity. Right. And, uh, I've said before, we're doing a lot of great stuff and a lot of great work for the people inside the life raft, the 1600 floating in the water still. We've got to figure this out better. Okay. Uh, and so I think, uh, awareness about that certainly find out what's going on. You know, we have. Uh, people deprived of housing here in London, a vote to estimates around, uh, 2000. So something like that. And if you figure a hundred on average,$150 per visit to the emerge, which is the only place they can get care if they even go right. Think of the dollars that that's, uh, using. Um, and so this is where again, and, uh, thinking outside the box outside of virtual care, putting nurses and docs in a Boston parking, the bus where they might be and regular rounds, right. Uh, with an app sack walking down the street, uh, and, uh, check out. Final commission model, right? Uh, for veteran's hospital. Uh, really cool. We're taking people are social. Sherpa's been through trauma themselves, recovered and trained in navigating the social system, uh, and building that trust with the people that are marginalized, literally going down under the bridge and with the tablet. Hey, you want to talk to the nurse? I can bring her online, like what a cool concept, that blend of technology, right. With reaching. So I think that's kind of where I'd inspire people to go with this.

Sully: 28:42

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