N.B. Medical Society calls for end of virtual ER pilot at 2 hospitals, warns of closures
Province's doctors says Horizon contract with Teladoc in Sussex and St. Stephen is misuse of $866K
The New Brunswick Medical Society is calling on Horizon Health and the Department of Health to cancel the virtual care service being tested at two rural emergency departments.
The professional association, which represents more than 2,000 physicians, argues that Horizon's contract with Teladoc Health Canada is a misuse of nearly $866,000 in a time of "crisis," and warns that it will lead to more small ERs closing.
Instead, the board of directors wants to see the funding redirected to providing increased access to urgent and primary care after-hours in the Sussex and St. Stephen areas, and to providing incentives for ER doctors to work in small, rural hospitals.
Virtual care solutions can be appropriate and safe "in the right clinical context," president Dr. Lise Babin told CBC News.
But New Brunswick doctors take issue with the one-year pilot Horizon launched at the Sussex Health Centre and Charlotte County Hospital in St. Stephen in late November to try to reduce wait times and improve access.
"We do not understand why our public authorities are contracting out these services to a … private sector human resource agency, at a premium to the taxpayer, when there was a range of less costly and more effective solutions to increase access to care available to them," Babin said in an email.
Other solutions she cited include adding an in-person ER physician, family doctors or nurse practitioners, or more virtual primary care in the community.
"We hope, at a minimum, that the lessons learned through the recent travel nursing scandal have been applied to the procurement and management of this contract," Babin said.
Of particular concern would be if New Brunswick physicians were hired by Teladoc "to then be sold back to us at a premium," she said.
'Less onerous' work for equal pay
Under the pilot, patients who visit the ER are assessed by an on-site triage nurse and registered. If they have non-life-threatening medical issues that can be dealt with virtually, they're offered the option to see a Canadian-based emergency-trained physician working remotely, via video.
On-site nurses and other health professionals assist the virtual doctor to diagnose and prescribe by performing assessments using Teladoc technology, such as electronic stethoscopes and handheld cameras.
The virtual doctors see mostly non-urgent or less urgent patients, which frees up doctors in the ER to focus on more critical patients.
The medical society is worried about the precedent Horizon is setting by paying virtual doctors the same as doctors who are on-site full time, treating the most critical patients, Babin said.
"Left unchecked, this approach will lead to more closures of small emergency rooms across the province as clinicians choose the less onerous option. … This risk is reinforced by adding a third-party with a profit motive to accelerate such a change."
ER doctor disputes data
An emergency room physician who works part time at the Sussex Health Centre and quit working for Teladoc in December has also taken aim against the pilot.
Dr. Robert Dunfield contends the virtual ER service is too slow, diverts nurses from helping more critical patients and is eroding the "gold standard" of emergency care.
Dunfield, 31, who splits his time between Sussex, where he grew up, and Halifax, disputes Horizon's recent update on the pilot.
Last week, Dr. Serge Melanson, Horizon's executive director of emergency medicine, said the virtual service being offered one or two days a week has already reduced the workload of the on-site ER doctors by 20 per cent.
Dunfield said he has worked 16 nine-hour shifts in the Sussex ER in the past month, seeing upwards of 30 to 40 patients each shift.
During a recent shift, 19 people registered within 30 minutes after the ER opened at 8 a.m. because of the overnight closure, he said.
Dunfield said the Teladoc doctor saw six people between 8 a.m. and 1 p.m., or about one patient per hour.
Dunfield didn't find this helpful, especially when they're the "lower-acuity patients that often need a quick assessment and prescription or some advice."
He said he could see those patients in an hour or two himself, after tending to more critical patients.
Virtual service improving, official says
In a followup interview Melanson stood by his 20 per cent reduced workload but said the figure was for early January, and Teladoc numbers have improved since the launch.
"Our most recent data shows that during a nine-hour virtual care shift we can see up to 23 patients," he said.
Data provided by Horizon shows Charlotte County Hospital saw a total of 1,157 patients over the 21 days the virtual service was available. Of those, 203, or 17.5 per cent, were seen virtually — roughly 1.7 an hour, as of mid-December and early January, up from one.
Sussex saw 1,173 patients over 20 days of the virtual service. Of those, 275, or 23 per cent, were seen virtually — roughly two an hour, up from one.
"We are providing a high-quality service to patients that they thoroughly enjoy, based on our satisfaction reports," Melanson said. "And we have a plan in place in the event that we cannot actually staff our facility with an in-person physician — we have a tool that can be deployed that can provide some measure of service to that facility."
Hurts 'global function' of ER team
Dunfield acknowledged patients might be seen by a virtual doctor faster than the six or more hours they might wait for an on-site doctor, who prioritizes the most critical cases.
Virtual doctors could also save in-person doctors like him from staying a couple of hours late so that everyone is seen, he said.
Still, it's a "high cost for a low volume of support."
The efficiency is just not there, which makes me unable to support it as a service in the department.- Robert Dunfield, Sussex ER doctor
"The efficiency is just not there, which makes me unable to support it as a service in the department," he said.
In addition, the virtual service ties up one or two nurses or advanced care paramedics, providing essentially primary care, when they could be in the ER, providing medication, taking blood, setting up an IV, reassessing vitals, ensuring patients get tests.
"I'm worried that if we start to accept this as a replacement for in-person emergency care, it's going to continue to erode the care that's provided in Sussex," Dunfield said. "And my biggest fear is the department will close some day. I don't want that to happen.
"I want my friends and family and the community and the people that use Sussex as a service area to get the highest standard of care — and timely care — that they deserve."
Contract details confidential
The medical society has requested public disclosure of the Teladoc contract to "understand the details."
CBC also requested a copy, but Greg Doiron, Horizon vice-president of clinical services, said last week it's confidential.
He confirmed the contract covers a one-time procurement and licensing cost; the equipment required to provide virtual care, as well as the setup of equipment, its maintenance and technical support, and the co-ordination of care and physician remuneration.
The $865,595 from the Health Department covers the cost of establishing and running the pilot in 2024-25, he said.
Babin said that if it's only a pilot, the medical society "would hope that there are clear cancellation clauses."
Horizon aware of 'important questions'
In a statement, Horizon president and CEO Margaret Melanson said the network is aware the society and other stakeholders have questions.
"We share the same goals as the NBMS and its members with respect to providing patients with access to timely care when and where they need it most and are committed to working together to achieve them," she said.
"We know face-to-face care provided by an emergency physician is the gold standard for emergency and urgent care. However, face-to-face care is not always possible."
Health Department spokesperson Sean Hatchard said the department is providing funding for this "temporary measure" based on a proposal it received from Horizon to address a "critical need" for ER doctors.
"Just like the New Brunswick Medical Society, the Department of Health is seeking long-term solutions to ensure New Brunswickers have access to the care they need when they need it." It is working to increase access to primary care through collaborative care clinics, he said.
Teladoc spokesperson Mariana Bockarova said Teladoc has programs with other provinces, such as Newfoundland and Labrador, demonstrating its ability to improve patient access, reduce physician burnout and prevent ER closures, she said.
The New Brunswick Nurses Union believes the virtual service "is more of a Band-Aid solution to a staffing shortage.
The union "will always be more supportive of prioritizing in-person practitioners over virtual care," president Paula Doucet said in an email.