A qualitative study on the Virtual Emergency Department care experiences of equity-deserving populations (2024) 

What is this research about? 

This is collaborative research between Access Alliance MHCS led by Dr. Akm Alamgir and Sunnybrook Health Science Centre led by Dr. Sander Hitzig. Founded on the principles of Appreciative Inquiry, whereby the strengths and experiences of all stakeholders are equally respected, this research examines the experiences of equity-deserving populations (EDPs) who received care from a Virtual Emergency Department (Virtual ED) in Toronto, Canada. The study aimed to understand how virtual care options compared to in-person care and what features promoted or hindered equitable access across diverse patient backgrounds. 

What Do You Need to Know? 

The research was conducted during a significant shift in healthcare delivery in 2020 due to COVID-19, when virtual care usage in Canada increased from 1.6% in 2019 to 70.6%. 

Key Context:  

• EDPs include racialized communities, people with language barriers, people being discriminated because of gender and sexual orientation, refugees/immigrants, people without any legal immigration status, people with disabilities, and other underserved groups. 
• Virtual EDs were established across Ontario to minimize in-person contact during the pandemic. 
• The service was designed for urgent but non-life-threatening medical issues. 
• Digital inequities, language barriers, and lack of private space can affect access to virtual care for EDPs. 

What Did the Researchers Do? 

Researchers conducted semi-structured interviews with 43 participants (36 patients and 7 family caregivers). Interviews were conducted via Zoom and lasted approximately 1 hour. Four interviews were conducted in participants’ native languages (Mandarin, Spanish, and Farsi). 

Researchers asked about reasons for accessing the Virtual ED, barriers, how it met care needs/expectations, and suggestions for improvement.  

What Did the Researchers Find? 

Most participants described previous negative in-person interactions when registering to see a physician or nurse or while sitting in an ED waiting room. They felt safer and better treated when they could bypass the in-person registration and waiting room experiences using the Virtual ED. 

The study identified three main themes:  

Inequities in In-Person Care:

• EDPs reported experiencing discrimination and culturally insensitive care in traditional ED settings while waiting to see the ED physician or nurse. One participant noted: “I feel like I am always taken for granted that I am not at the highest seriousness when I’m clearly experiencing an [asthma] attack.” 
• This included unnecessary questioning about their identity or medical conditions and disrespect, neglect and/or overt racism directed towards them. 

Virtual ED Benefits: 

Participants described their experiences with the Virtual ED in several ways: 

• Increased safety and control: 
  • Many participants felt the Virtual ED provided a “safer” and more controlled environment compared to in-person ED visits.  
  • The service allowed patients to bypass potentially discriminatory waiting room experiences. 
  • Participants felt more in control of their care, with one noting “I felt safer doing it virtually than I would going in, especially with my mental health. It can be negatively affected by being in hospitals.” 

• Improved accessibility and convenience: 
  • Participants highlighted the ease, convenience and flexibility of the Virtual ED, including the online booking system. 
  • They appreciated not having to travel to the ED or wait for long periods to see a physician. Some noted it allowed them to have family members present during the appointment, which was not always possible with in-person visits due to COVID-19 restrictions. 

• More equitable and culturally sensitive care: 
  • Many participants felt they received more respectful and validating care through the Virtual ED compared to past in-person experiences.  
  • One participant noted: “They did not cut me off when I was speaking. They did not say that I was incorrect for how I was feeling, so I was not invalidated in any way.” 

Areas for Improvement:

• Virtual care cannot replace in-person care for certain medical issues requiring a physical exam. 
• Greater promotion of the service to specific communities is needed. 
• Virtual ED service providers need to target outreach to raise awareness among equity-deserving communities. 
• Participants suggested improvements like displaying pronouns, enhancing cultural sensitivity, and increasing awareness within EDP communities to make the Virtual ED more inclusive. 
• Participants recommended increasing language support for non-English speakers. 
• Challenges using the Virtual ED included language barriers, lack of awareness about the Virtual ED, and digital equity challenges (e.g., needing a computer with high-speed internet and Zoom access), and limited private space to have a confidential appointment. 
• Some experienced technical challenges, especially if using smaller devices like smartphones instead of computers. 

How Can You Use This Research? 

For Healthcare Providers:  

• Providers need to not only explore barriers to virtual urgent care for EDPs but also, to learn from people from diverse EDP communities on their overall perceived quality of the care experience. 
• Provide cultural competency training for all staff interacting with patients.  
• Develop strategies to make virtual care more accessible.  Consider displaying staff pronouns and using inclusive imagery in virtual care settings. 
• Consider offering services in multiple languages.  
• Develop partnerships with community organizations serving EDPs to improve service delivery and awareness.  
• Implement targeted outreach to raise awareness of Virtual ED services among EDP communities to ensure that information about the Virtual ED is widely disseminated. 

For Healthcare Administrators:  

• Expand Virtual ED services while maintaining quality.  
• Increase promotion of virtual services to EDPs. Enhance virtual platforms to be more inclusive and accessible (e.g., multiple languages, accommodations for disabilities). 
• Develop policies to ensure equitable access. Help with those who may struggle with the technological requirements of virtual care, such as help lines or step-by-step guides. 

For Researchers:  

• Further investigate barriers to virtual care access. 
• Study long-term outcomes of Virtual ED services. 
• Examine effectiveness of targeted outreach strategies. 

Study authors and journal/book name 

Authors: Justin N. Hall, Abirami Vijayakumar, Logan Reis, Akm Alamgir, Kristina M. Kokorelias, Julia Hemphill, Noorin Pattni, Laurie Legere, Ilana J. Halperin, Lisa Di Prospero, Debbie Elman, Sharon Domb, Dana Arafeh, Cliff Ledwos, Christine L. Sheppard, Sander L. Hitzig 

Publication: PLoS One 19(6): e0304618. (original link) 

Related Access Alliance Activities 

Best Practice Standards for Remote Program and Service Delivery 
This organizational initiative and its accompanying Guide is called the Standard Guide for Incorporating Remote Program and Service Provision into a Multi-modality Service Delivery Approach. It is important to note that remote service delivery is not meant to replace in-person service and programs, but rather to incorporate another option for clients to access our programs and services. 

Innovative E-Solutions for Promoting Collaborative Mental Healthcare 
Vulnerable client communities we serve (immigrants, refugees, non-status, racialized groups, low-income families) face elevated risk for mental health issues. However, these very groups encounter many institutional (e.g lack of culturally sensitive care, language barrier, time constrains of primary care providers) and social barriers (e.g. stigma) in talking about and accessing mental health services. The key goal of this project was to assess the role and effectiveness of an e-health screening tool (iCCAS) to improve mental healthcare for vulnerable client groups. 

Building Capacity for Equity-Informed Planning and Evaluation 
The overall aim of this project was to build organizational level knowledge, commitment and capacity to routinely use a health equity framework and evidence geared at overcoming systemic inequities in healthcare access, healthcare quality and health outcomes. 

Reducing Appointment No-Shows: Understanding Determinants and Solutions 
The key goal of this study was to investigate social and health system level determinants of appointment no-shows at a community health centre (Access Alliance). The end goal of this project is to identify evidence-informed institutional solutions and best practices for reducing appointment no-shows. 

For more information contact research@accessalliance.ca