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Ontario Medical Review
April 28, 2021

OntarioMD partners on remote patient monitoring pilot that yields benefits for high-risk patients in northern Ontario

The latest example of how digital tools are playing a role in the pandemic response

by Sarah Hutchison LLM, MHSc
CEO, OntarioMD

High-risk patients in northern Ontario who may be self-isolating and have lung, heart and other chronic conditions are benefiting from remote patient monitoring in a new virtual program being piloted by OntarioMD and Ministry of Health partners in the latest initiative within the province’s pandemic response. 

Through our award-winning i4C (Insights4Care) Program, OntarioMD has enabled clinicians to more easily identify patients with key health indicators such as COPD, congestive heart failure or diabetes who would benefit from remote monitoring and referral to the provincial Telehomecare program. After receiving a referral, Telehomecare can proactively respond to flags indicating improvement or decline of the patient’s health and provide timely reports about the patient’s progress to their primary care physician via Health Report Manager (HRM®). This is a positive outcome for the system overall where Telehomecare can improve the patient experience for timely and accessible care at home.

From the patient perspective, the virtual care pilot ensures vulnerable populations don’t fall through the cracks and are able to get the care they need, even during the pandemic, when some may be less likely to seek treatment. This continuity of care—all from the convenience of home—for vulnerable patients in remote regions at this time in our pandemic reality also reduces unnecessary clinic and hospital visits which can add to the risk of exposure to and transmission of the COVID-19 virus.

Like other emerging digital and virtual solutions, this modern approach to health care promotes patient engagement, giving patients a feeling of satisfaction, knowledge and empowerment as they get involved in managing their own care. The pilot runs from February 2021 through to June 2021, and a sustainability plan is being developed by Ontario Health as it considers expansion to other regions. It’s just one of the many examples within OntarioMD’s catalogue of digital solutions that support clinicians as they manage patient care and the transformation of health care in our fast-changing world.

When the World Health Organization declared a pandemic in March 2020, Ontario’s health-care system delivery partners were able to deploy digital solutions to health care as care shifted to virtual encounters and physical distancing requirements required new ways to interact with patients. A year later, it’s clear that virtual solutions are here to stay.

This particular solution for high-risk patients in northern Ontario supports several health-care priorities including population health management and integrated care delivery, while also addressing what might otherwise be gaps in care for people in remote areas of the province. Primary care providers who have participated in the pilot say this virtual care solution also reduces the administrative burden on them and their clinics as they manage their higher-risk patients.

By combining two i4C services and HRM in this remote care model, we are also facilitating effective care coordination, closed-loop referral management and ensuring primary care physicians and their staff have the tools and supports to manage patients and improve their outcomes.

Martha Musicco, who represents Telehomecare as Director Home & Community Care for the North East Local Health Integration Network, says the virtual care pilot is resulting in more quality referrals to the program. “We are seeing more Indigenous and rural patients who need supports within the health-care system being referred to Telehomecare because the referral process for primary care providers and nurses who monitor patients remotely is now streamlined,” Musicco said recently. “By leveraging digital health-care solutions, we’re able to improve access to care while also supporting health system capacity.”

Cori Watson, of the North West Local Health Integration Network (LHIN), added that not only does the pilot provide medical home care for patients who need it, it also addresses population health management and is a prime example of integrated care delivery. “In this integrated system, the needs of high-risk patients in remote locations are being met, while also reducing administration for primary care providers and their clinics,” Watson said. 

Throughout the pandemic, there has been a significant increase in the number of visits provided virtually in-home and through community care, and we have heard from home and community care service providers that investments are needed to support technical capacity to provide virtual care. This is a first step to enhancing home and community care organizational capacity to deliver high quality virtual care during the pandemic—and afterward.

At OntarioMD, we pride ourselves in being a leader in providing digital health solutions in the transformation of health care, and we also take care to ensure users of our tools are comfortable and have the skills to optimize their use. As a result, through this pilot, we are also providing proven change management methods, training and coaching to 50 primary care providers who are participating in the pilot through our i4C Advisory Service. The initiative received provincial funding through Ontario’s Fall Preparedness Plan, which dedicated $9.5 million to remote patient monitoring programs. Virtual care options are key in ensuring continuity of health services while preventing the spread of COVID-19.

Digital platforms and tools are playing an increasingly prominent role in connecting and integrating systems, people and health information. Now more than ever, it’s crucial that technology evolves and adapts to find new and innovative ways to enable all of the essential components of patient care to come together to integrate our increasingly complex health-care system. OntarioMD is playing a leading role. We believe digital innovation can power a healthier Canada. 

Today, more than 21,000 Ontario clinicians and their staff have adopted EMRs and provincial digital products connected to them. For example, through Health Report Manager, clinicians using an OntarioMD-certified EMR can securely receive electronic patient reports from hospitals and specialty clinics directly into patients’ charts, eliminating paper and saving time. And the Insights4Care Dashboard is an EMR-integrated population health management tool that provides insights about patients at a glance to help turn data into better outcomes through preventive care and management of chronic illnesses. Technology has moved the dial in health-care delivery since the pandemic took hold more than a year ago, and it will continue to drive transformation over time.

Learn more about OntarioMD's suite of digital tools, or contact