Has virtual healthcare reached a tipping point in Canada and become an established part of our healthcare system, or was its increase during the COVID-19 pandemic a temporary response to unique circumstances? A recent publication by an international consulting firm asserts that not only has an inflection point been reached, but that virtual care must be made permanent for the healthcare system to remain sustainable [1]. The challenge for emergency physicians will be determining the role that emergency departments (EDs) should play in this care revolution. Lessons from early adopters of virtual emergency care will inform our path forward. In this issue of CJEM, Stuart and colleagues [2] describe the experiences of pediatric ED physicians using a virtual platform to care for children with mental health concerns. Offered during the first year of the COVID-19 pandemic, parents and caregivers completed online screening questions and booked virtual appointments. When possible, a mental health nurse or crisis worker joined appointments [2].

Several pediatric EDs in Canada have reported feasibility and acceptability of virtual care [3, 4]. Stuart and colleagues add unique contributions to this body of literature. They report that the majority (67%) of surveyed ED physicians believed that virtual mental healthcare benefits patients. While 64% felt that care was safe, only 36% endorsed feeling confident of the quality of care they provided. What might explain this low confidence? Analysis of the study’s qualitative data suggests that many physicians cited insufficient time to meet patient needs, and some questioned whether emergency physicians were the right individuals to deliver the needed care [2].

We believe virtual care has the potential to add value to the care of children with urgent mental health needs. The key will be, as Stuart and colleagues suggest, making sure the right patient is seen by the right provider at the right time with the right resources. If EDs simply add staff to provide virtual care without carefully situating the service in the system of mental healthcare in the community, it is possible that demand for the service will rise, but that care may become fragmented. Patients struggling with mental health concerns are best served by a connected mental healthcare system that spans community and hospital settings. The community setting often delivers better patient experience and better continuity at a lower cost; therefore, virtual ED mental health services must avoid drawing patients away from community providers, and virtual ED discharge planning should include facilitating community care. A recently released White Paper from the Institute for Healthcare Improvement describes the ED & UP Learning Community which set as its goal to improve ED mental healthcare through coordination with “upstream” community partners [5]. One suggested method of coordination was to provide virtual access to mental health triage, consultation, and treatment. In a coordinated system of care, patients could be referred to a virtual ED from their primary care provider or community partner with specific concerns. A virtual ED consultation, either with the patient or the referring provider, could be a useful and patient-centered method to determine whether a patient should attend the ED in person. Such a structure, with a clear purpose and outcome for encounters, could improve ED physician confidence in care quality and also promote continuity of care.

Models for provider education and interprofessional teamwork require further development, and findings from the study by Stuart et al. reinforce these needs. While ED physicians believed that virtual care was valuable, 28% reported difficulties building rapport and 36% did not feel at ease providing virtual care. In 2020, the Canadian Medical Association, College of Family Physicians of Canada, and the Royal College of Physician and Surgeons of Canada published recommendations for supporting the medical profession in delivering virtual services and ensuring that learners develop needed competencies [6]. Sharma and colleagues [7] provide an overview of competency domains that could be readily incorporated into education: (1) digital communication and ‘webside’ manner (e.g., relational and technical skills), (2) scope and standards of care (e.g., privacy, prescribing), and (3) virtual clinical interactions (e.g., management of group interactions). In the study by Stuart et al. [2], physicians emphasized the importance of partnering with mental health clinicians to deliver virtual care. Pathways that utilize an interprofessional team approach with mental health nurses, social workers, or other skilled professionals can enhance feasibility by reducing time demand for emergency physicians, who are often in relative short supply.

Virtual health innovations must be evaluated to ensure that intended outcomes are achieved, including promoting positive patient and healthcare provider experiences and controlling cost. Several models of ED virtual mental healthcare, such as the one described by Stuart et al., showed promise during the early pandemic but were not sustainable after ED volumes rebounded and providers were again needed to provide in-person care. Early models should not be propped up simply by adding resources. Patients and families have demonstrated their desire to access care on convenient virtual platforms, as evidenced by the popularity of both public and private virtual care offerings. Simply adding resources to a highly accessible ED service will not result in patients receiving the right care in the right place and time and may instead increase demand and draw care away from community providers. The essential next step in contemplating the future role of virtual ED mental healthcare is determining how to meet patient needs in a manner that enhances quality and value in the system of mental healthcare. With one of the defining features of EDs being perpetual availability, our mental health system will not be well served by increasing ED services without simultaneously increasing coordination and access to community resources. As emergency care providers, we must embrace the reality of virtual care as a core component of a modernizing health system and simultaneously use our early pandemic learnings to develop virtual applications that enhance mental health outcomes for our patients and for our healthcare system.